Signal Passed at Danger by Train ST24, Junee, New South Wales, on 9 September 2009

Executive summary

At about 1411 on Wednesday 9 September 2009, scheduled XPT passenger train ST24, en route from Melbourne to Sydney, passed signal JE02 at Junee by about 33 m while that signal was displaying a Stop (red) indication. No injuries or damage resulted from the occurrence.

The driver of ST24 said that signal JE26, the signal before JE02, was displaying a Medium Turnout indication and this meant that signal JE02 would be showing a Proceed aspect. Several other rail employees also said that signal JE26 was displaying a Medium Turnout indication. However, the investigation concluded that it was almost certain that signal JE26 was displaying a Caution Turnout indication rather than a Medium Turnout indication, which would have resulted in signal JE02 displaying a Stop indication. The investigation concluded that the driver's perception of signal JE26 was influenced by expectation, distraction and possibly fatigue, and that the employee witnesses' perception of the signal was influenced by expectation, 'confirmation bias' and 'group think'.

The report identifies three safety issues in relation to prioritisation of operational tasks, signal lamp voltage and signalling design standards.