Recommendation RR20070033

Recommendation issued to: TransAdelaide

Recommendation details
Output No: RR20070033
Date issued: 20 December 2007
Safety action status:
Background: Why this Recommendation was developed

Output text

Safety Issue

It is possible that departure procedures at Adelaide station could increase the risk of 'Starting Against Signal' SPADs due to expectation error. Platform coordinators give RoW at the scheduled departure time regardless of any delay to clearing the departure signal. Under these conditions, it is possible that drivers would move off and slowly approach the signal with an expectation that it would clear as they approached increasing the risk of an error if the signal remained red.

Safety Recommendation

The Australian Transport Safety Bureau recommends that TransAdelaide undertake further work to address this safety issue.

Initial response
Date issued:
Response from: TransAdelaide
Response text:

TransAdelaide acknowledged that signal anticipation is a potential cause of SPADs and have included the risk in their risk management plan. TransAdelaide has also initiated SPAD awareness programmes to educate drivers on the risks associated with signal anticipation.

ATSB response:

The ATSB acknowledges TransAdelaide's pro-active approach to SPAD mitigation associated with signal anticipation. However, since TransAdelaide's investigation process was unlikely to have provided a clear understanding of factors that may have contributed to past SPADs, it is unlikely that the factors contributing to signal anticipation could have been identified for all scenarios.

This issue is reflected in TransAdelaide's risk management plan in which the recommended actions to control signal anticipation risk is related to training programs and rigorous application of performance management systems (treatments addressing human error factors). If TransAdelaide considers why drivers anticipate a signal clearing, further opportunities may be identified to control the risk.

As mentioned previously, this observation only indicates that the process was considered incomplete and does not indicate that the outcome was incorrect in every case. TransAdelaide may identify further opportunities to improve railway safety if it considers this safety issue further.

Last update 05 April 2012