Rail safety investigations & reports
Collision between suburban passenger trains G231 and 215A in Adelaide Yard, SA, 24 February 2011
RO-2011-002

Summary
At 1209 on 24 February 2011 a suburban commuter train (215A)
with 17 passengers on board was being routed from the Up South Main
Line into platform 5 at the Adelaide Station. At about the same
time a second commuter train (G231) with 22 passengers on board
that was departing the Adelaide Station passed signal 141 located
at the end of platform 3 at low speed. Shortly thereafter both
drivers realised that their trains would come into conflict and
applied their train brakes but it was too late to avoid a
collision. There were no injuries as a result of the collision;
however, both trains sustained minor damage.
The ATSB established that the driver of train G231 received a
'yellow' Right of Way flag from the Platform Coordinator,
indicating that platform work was complete and that the train could
advance up to signal 141 which was displaying a stop (red)
indication.
It was concluded that as the train approached signal 141 the
driver diverted his attention onto a lesser task of checking train
notices and did not concentrate on the more important task of
observing the status of signal 141. Subsequently he perceived that
signal 141 had changed to a 'proceed' aspect, although the
investigation subsequently established that it did not clear at any
stage prior the SPAD event and continuously displayed a stop (red)
indication for the passage of train G231.
In the interests of enhancing future rail safety the ATSB
identified a number of safety issues which included the dispatching
of trains towards starting signals, the level of protection
afforded by the train's dead man's control and Automatic Warning
System and a range of opportunities to reduce the risk of human
performance error. The ATSB is satisfied that the actions proposed
in response by Public Transport Services adequately address each of
the safety issues.
Preliminary
Preliminary report: 21 Aprl 2011
At 1209 on 24 February 2011 a suburban passenger train (215A) with 17 passengers on board was being routed from the Up South Main Line into number 5 platform at the Adelaide Railway Station. At about the same time a second passenger train (G231) with 22 passengers on board that was departing the Adelaide Railway Station passed signal 141 located at the end of number 3 platform at low speed. The signal was displaying a stop (red) indication.
A short time later the drivers of both trains realised that they would come into conflict and applied their train's brakes, too late to avoid a collision. There were no injuries as a result of the collision but both trains sustained minor damage.
The investigation is continuing
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Safety Issues
Dispatching trains against starting signal
Public Transport Services procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.
Issue number: | RO-2011-002-SI-01 |
---|---|
Who it affects: | All rail operators |
Status: | Adequately addressed |
Vigilance control
As a defence against driver error Public Transport Services provide their railcars with a vigilance system comprising a deadman’s control and an Automatic Warning System. However, the current system does not protect against ‘Starting against Signal’ SPAD events as occurred at Adelaide Station.
Issue number: | RO-2011-002-SI-02 |
---|---|
Who it affects: | All rail operators |
Status: | Adequately addressed |
SPAD Investigation Form
SPAD Investigation Form (RS-ADL-283) used by Public Transport Services does not collect data on many of the human factor issues that would facilitate a better understanding of why SPADs are occurring.
Issue number: | RO-2011-002-SI-03 |
---|---|
Who it affects: | All rail operators |
Status: | Adequately addressed |
Human factors driver training
Public Transport Services driver training does not adequately address the risk of distraction and areas of human performance error with respect to SPAD events.
Issue number: | RO-2011-002-SI-04 |
---|---|
Who it affects: | All rail operators |
Status: | Adequately addressed |
Interactive driver training
Public Transport Services have not implemented simulator training or a similar interactive system which would allow new drivers to practice, retain and apply what they have learned without the risks associated with driving trains in traffic.
Issue number: | RO-2011-002-SI-05 |
---|---|
Who it affects: | All rail operators |
Status: | Adequately addressed |
Inconsistencies between RoW procedures
There are inconsistencies between Right of Way procedures used by platform coordinators and passenger service attendants.
Issue number: | RO-2011-002-SI-06 |
---|---|
Who it affects: | All rail operators |
Status: | Adequately addressed |
Inconsistencies between Work Instructions and the Common General Operating Rules
There are inconsistencies between Right of Way Work Instructions and the Common General Operating Rules.
Issue number: | RO-2011-002-SI-07 |
---|---|
Who it affects: | All rail operators |
Status: | Adequately addressed |
Fatigue management
Public Transport Services do not have a formal fatigue policy/procedure.
Issue number: | RO-2011-002-SI-08 |
---|---|
Who it affects: | All rail operators |
Status: | Adequately addressed |
General details
Date: | 24 February 2011 | Investigation status: | Completed | ||
Time: | 1209 CDT | Investigation level: | Systemic - click for an explanation of investigation levels | ||
Location (show map): | Adelaide Railyard | ||||
State: | South Australia | ||||
Release date: | 11 October 2011 | Occurrence category: | Serious Incident | ||
Report status: | Final | Highest injury level: | None |
Train 1 details
Train registration | G231 | |
---|---|---|
Type of operation | Suburban passenger | |
Damage to train | Minor | |
Departure point | Adelaide, SA | |
Destination | Oaklands, SA |
Train 2 details
Train registration | 215A | |
---|---|---|
Type of operation | Suburban passenger | |
Damage to train | Minor | |
Departure point | Belair, SA | |
Destination | Adelaide, SA |