Rail safety investigations & reports

Multiple SPAD by freight train 9837 at Hurlstone Park, NSW on 30 January 2013

Investigation number:
Status: Completed
Investigation completed


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What happened

On 30 January 2013, Pacific National freight train 9837, travelling from Nowra to Orange, passed signals SM109G and SM115G at stop on the Down Goods line between Dulwich Hill and Hurlstone Park in Sydney. Just prior to this incident a work crew had been working on the track under the protection of Absolute Signal Blocking (ASB). There were no injuries or damage.

What the ATSB found

The ATSB’s investigation found that the train crew did not take action in response to the indications of three consecutive signals, resulting in the passing of two of those signals at stop without authority (also called a SPAD). It was found that the more senior co-driver had inadvertently fallen asleep on the approach to these signals. The trainee driver, in a reduced state of alertness, missed the first signal at caution, and the next signal at stop. He applied the brakes once the train passed the final signal at stop after realising this signal applied to his train.

Two persons from a litter pickup work crew were on the track just before the train passed through their worksite. Once alerted to the train’s approach they moved off the tracks and to a safe place behind the platform at Hurlstone Park station.

A number of Pacific National’s policies and procedures were examined to determine if any area of the management or training of the train crew contributed to the incident. Fatigue management, and in particular over- reliance on the use of bio-mathematical model scores used to roster train crew, was one area where improvement was needed. The ATSB also found that there was an absence of adequate procedures and training for drivers who were performing co-driving duties while coaching trainee drivers.

What's been done as a result

As a result of the incident Pacific National has undertaken a range of actions to improve its approach to fatigue management and the implementation of fatigue training. They have also commenced a review of SPAD risk management processes and training requirements for coach/tutor drivers. A trial has commenced of improved data loggers for the Bulk Rail fleet.

Safety message

In order to minimise fatigue-related errors, rail operators should ensure that fatigue management systems incorporate integrated and multi-layered risk control mechanisms. Rail operators should also recognise that the training of drivers by advanced drivers during operations increases exposure to workload and other risks that need to be managed. In addition, SPAD strategies devised by rail operators should have regard to broad systemic issues rather than focus simply on individual train crew actions.

Download final report
[Download  PDF: 2.07MB]

Safety Issues

Go to RO-2013-003-SI-01 - Go to RO-2013-003-SI-02 - Go to RO-2013-003-SI-03 - Go to RO-2013-003-SI-04 -

Fatigue management system

Pacific National's fatigue management system is over-reliant on the use of a bio-mathematical model to predict individual fatigue risk, being based principally on rostered work hours without due consideration to higher level fatigue risk management strategies.

Safety issue details
Issue number: RO-2013-003-SI-01
Who it affects: All rail operators
Status: Adequately addressed

Fatigue management training

Pacific National Bulk Rail division did not provide training on fatigue management to the driver.

Safety issue details
Issue number: RO-2013-003-SI-02
Who it affects: All rail operators
Status: Adequately addressed

Training for coach/tutor drivers

Pacific National Bulk Rail does not provide coach/tutor drivers with sufficient training and direction as to how to perform their role.

Safety issue details
Issue number: RO-2013-003-SI-03
Who it affects: All rail operators
Status: Adequately addressed

SPAD strategy

Pacific National’s SPAD strategy focuses on individual crew actions and the costs of SPADs, rather than developing integrated error tolerant systems of work with regard for the broader systemic issues known to contribute to SPAD events.

Safety issue details
Issue number: RO-2013-003-SI-04
Who it affects: All rail operators
Status: Adequately addressed
General details
Date: 30 January 2013   Investigation status: Completed  
Time: 0229 EDT   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Hurlstone Park    
State: New South Wales    
Release date: 15 November 2013   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Pacific National  
Train operator Pacific National  
Train registration 9837  
Type of operation Freight  
Sector Freight  
Damage to train Nil  
Departure point Nowra, NSW  
Destination Orange, NSW  
Last update 03 April 2020