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Interim Recommendation issued to: TransAdelaide

Recommendation details
Output No: IR20060009
Date issued: 13 April 2006
Safety action status:
Background: Why this Interim Recommendation was developed

Occurrence No: 2006003
Occurrence Date: 28 March 2006

BACKGROUND

At approximately 0700 on 28 March 2006, TransAdelaide train H307 passed signal 161 at Adelaide Station while displaying a red indication.

The investigation team has been advised that train H307 was positioned approximately 15 to 20 metres from signal 161 in preparation for departure from Adelaide Station. In accordance with TransAdelaide departure procedures, a Platform Coordinator was positioned approximately 10 metres in front of the railcar to give a "Starting" hand signal. The driver of train H307 then departed the platform; however train H307passed signal 161 while a red indication was displayed.

ANALYSIS

During early stages of the investigation the Australian Transport Safety Bureau (ATSB) gathered evidence suggesting that a number of factors contributed to train H307 passing signal 161 while displaying a red indication.

TransAdelaide's "Common General Operating Rules" (dated 22 November 2000) defines the "Starting" hand signal (i.e. guard's signal to driver to start train) in rule 43(k). This rule states that therequired signal is a "Green light waved above the head…". However, the investigation has been advised that Platform Coordinators indicate a "Starting" hand signal using a steady green light held by an outreached horizontal arm. A steady green light is defined in rule 43(m) as an "All clear or proceed" signal which is equivalent to a clear or proceed line side signal.

In addition to hand signalling methods that are inconsistent with operating rules, it is likely that the position of the Platform Coordinator and the outreached arm may have obscured, or partially obscured, signal 161. Under these conditions it is possible that the driver of train H307 only observed a green light before departing the platform.

The ATSB is continuing its investigation.  However, in view of the evidence to hand the ATSB has made the following interim recommendation under section 25 of the Transport Safety Investigation Act 2003. Please note that this interim recommendation in no way prejudges the final conclusions that may be reached in the ATSB's final report into this accident.

Output text

Interim Recommendation IR20060009

The ATSB recommends that TransAdelaide:

  • Review the departure procedures for Adelaide Station to ensure that Platform Coordinators provide railcar drivers with clear, unambiguous "Starting" signals, consistent with TransAdelaide's "Common General Operating Rules".
  • Ensure that hand signals do not obscure a driver's view of line side signals.
 
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Last update 05 April 2012