The ATSB has released its interim report into a signal passed at danger resulting in a near-miss between two suburban passenger trains at Bowen Hills, Queensland, on 10 January 2018.
The ATSB found train TP43 passed through signal ME45 while the signal displayed a stop indication. A signaling system generated an alarm to the network control officer at the Rail Management Centre, who issued an emergency stop command to the driver. The driver responded to the stop command and brought the train to a stop 125 m before the potential conflict point with another train, some 220 m past signal ME45.
During the course of the investigation, the ATSB found cause to examine Queensland Rail’s (QR) driver-competency management process or maintenance of competency (MOC) assessments.
After the incident the driver underwent a post-incident track observation that identified a number of safe driving deficiencies that were not in their previous MOC assessments.
Further examination found the driver’s detailed written responses in each MOC, were identical or near identical to those in the marking guide, with limited incorrect answers noted in the assessment.
Based on these findings, the ATSB analysed more than 50 systematically selected MOC assessment samples. Almost all showed a similar pattern.
ATSB is not stating that QR’s Citytrain drivers are not competent; rather, the application of the process for assessing competency has significant limitations
In response the ATSB released a safety issue to QR in September 2018 outlining its concern that the administration of their MOC assessment process provides limited assurance its Citytrain Rail Traffic Drivers meet relevant competency requirements.
In doing this, the ATSB is not stating that QR’s Citytrain drivers are not competent; rather, the application of the process for assessing competency has significant limitations.
The ATSB will continue to monitor QR’s response to the safety issue.
The investigation is continuing and will include an examination of among others policies, procedures and guidance related to the administration of train driver MOC assessments as well as processes used by QR to monitor the administration and effectiveness of the train driver MOC process.
The investigation is expected to be completed in the third quarter of 2019.Last update 27 February 2019