Signal MR5 Passed at Danger, Freight Train Y245, Murarrie, Queensland, on 28 June 2004

Executive summary

Train Y245 passed signal MR5 at stop by 81.8 metres, about 500 metres short of a conflicting freight train movement. The driver of Y245 had previously passed a caution signal but, when only 439 metres from signal MR5, increased power as if proceeding on clear signals. When about 200 metres from signal MR5, an emergency brake application was made. The train controller supervising this section of track was temporarily absent from the workstation and this contributed to the 16 seconds it took to relay an emergency 'stop' radio transmission.

Train Y245 was crewed by a driver as the sole crew member and, apart from the locomotive vigilance devices, there were no secondary protection devices such as Automatic Warning System, Automatic Train Protection or Automatice Train Control at this location. The driver of train Y245 died on 26 October 2004 following a severe coronary episode. This and his previous involvement in SPAD incidents, where loss of concentration had been cited as a causal factor, led to the examination of this driver's state of health. This in turn led to an examination of the medical standards applicable to Queensland Rail drivers.

The investigation found that, while it was unlikely that partial incapacitation was a factor in the SPAD at signal MR5, the possibility could not be ruled out. It was also found that the investigations reports into the driver's previous SPAD incidents focused on the active factors in lieu of latent or systemic factors. Additionally, it was found that the process of returning this driver to full duties following previous SPAD's seemingly followed set patterns. Once returned to full driving duties, little evidence of additional monitoring or supervision was produced during this investigation.