Rail safety investigations & reports

Signal RS57 passed at danger involving suburban passenger train 1W33, Roma Street Station, Queensland on 5 September 2017

Investigation number:
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On the 5 September 2017, Queensland Rail suburban passenger train 1W33 was being transferred from Mayne Depot to Roma Street Station, Brisbane, Queensland, as a non-revenue operation. Nearing the Roma Street Station at 1628, train 1W33 passed signal RS57 at danger. Signal RS57 was displaying a stop indication (red aspect). Train 1W33 ran through points 226 and travelled east into platform 8. At the same time, another train (15X2) was approaching Roma Street Station on a converging route from the east.

As the train passed signal RS57 at danger, a ‘signal passed at danger’ (SPAD) alarm was generated in the Queensland Rail Management Centre. The Network Control Officer broadcast an emergency call to 1W33 and converging train 15X2. Both trains came to a stop approximately 550 m apart.

The rail infrastructure (points 226) was damaged by train 1W33. There were no reported injuries or damage to the rolling stock.

What the ATSB found

The ATSB found that the driver of 1W33 was distracted from his primary task of driving the train, including observing and reacting to signals, by personal emotional thoughts, when approaching signal RS57 displaying a stop indication.

What's been done as a result

Queensland Rail has initiated a number of strategies to manage the risk of SPADs, including administrative processes, human factors analysis, plus reviews and improvements to existing SPAD controls.

Longer term, Queensland Rail have sought expressions of interest from market leaders to partner with Queensland Rail to implement European Train Control System (ETCS) on sections of the Queensland Rail network. ETCS incorporates automatic train protection that provides for monitoring of train speed and limits of authority to ensure trains stay within designated speed limits and authorised safeworking limits.

Safety message

This incident highlights how distraction increases the risk of a SPAD event. Distractions can be external, but internal thoughts related to significant personal events or circumstances can take away a driver’s attention from their primary task of safely managing the train.

Queensland Rail suburban passenger train 1W33
Queensland Rail suburban passenger train 1W33
Source: Queensland Rail

Download final report
[Download  PDF: 1.76MB]

The occurrence

Safety analysis


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General details
Date: 05 September 2017   Investigation status: Completed  
Time: 1628 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Roma Street Station   Investigation phase: Final report: Dissemination  
State: Queensland    
Release date: 06 March 2018   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Queensland Rail  
Train operator Queensland Rail  
Train registration 1W33  
Type of operation Suburban passenger train  
Sector Passenger - metropolitan  
Damage to train Nil  
Departure point Mayne Rail Depot, Qld  
Destination Northgate, Qld  
Last update 14 November 2018