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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

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[ Download PDF: 1.76MB]

The occurrence

Safety analysis


Safety action

Sources and submissions

General details
Date: 05 September 2017 Investigation status: Completed 
Time: 1628 EST Investigation phase: Final report: Dissemination 
Location   (show map):Roma Street Station Investigation type: Occurrence Investigation 
State: Queensland Occurrence type: SPAD (signal passed at danger) 
Release date: 06 March 2018  
Report status: Final Occurrence category: Incident 
 Highest injury level: None 
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
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Last update 14 November 2018