Rail safety investigations & reports

Signal ME45 passed at danger involving suburban passenger train TP43 and near collision with another suburban passenger train, Bowen Hills, Queensland, on 10 January 2018

Investigation number:
RO-2018-002
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On 10 January 2018, a Queensland Rail (QR) Citytrain suburban passenger train (TP43) was en route to Brisbane Domestic Airport, Queensland, with a scheduled crew change at Bowen Hills. While the train was stopped at Bowen Hills, the departure signal (ME25) at the northern end of No.2 platform was displaying a yellow aspect, which meant that at that time the next signal (ME45) was displaying a red aspect (stop indication).

After departing the platform, TP43 exceeded its limit of authority by passing signal ME45, which was still displaying a red aspect (stop indication). After receiving a signal passed at danger (SPAD) alarm, the network control officer broadcast an emergency stop command to the driver of TP43. The train was stopped 220 m past signal ME45, and 126 m prior to a conflict point. At the time that TP43 came to a stop, another suburban passenger train had just cleared the conflict point.

What the ATSB found

When approaching signal ME45, the driver of TP43 probably read through to another signal for an adjacent line that was displaying a green aspect, which they incorrectly believed was signal ME45.

The Citytrain rail network was fitted with an automatic warning system (AWS) that provided a driver with an audible and visual alarm when approaching a restricted signal. If the driver did not acknowledge the alarm, the AWS would generate a penalty brake application. Although the driver of TP43 acknowledged the AWS alarm on approach to signal ME45, this was almost certainly an automatic response, and did not result in the driver effectively checking the aspect of the signal. Therefore, the signal’s red aspect was not detected.

The AWS provided the same alarm for all restricted signals (that is, double yellow, yellow, flashing yellow and red aspects). The potential for habituation, and the absence of a higher priority alert when approaching a signal displaying a red aspect, reduced the effectiveness of the AWS to prevent SPADs. This placed substantial reliance on procedural or administrative controls to prevent SPADs, which are fundamentally limited in their effectiveness.

The ATSB found that QR’s administration of the train driver maintenance of competency (MOC) process provided limited assurance that its Citytrain train drivers met relevant competency requirements. It should be noted that the ATSB is not suggesting that Citytrain drivers were not competent; rather, the application of the process for assessing competency had significant limitations in assuring the drivers’ competency. Nevertheless, following this occurrence, the driver of train TP43, who was very experienced, was found not to meet the relevant competency requirements even though their previous MOC assessments showed no indications of any problems.

The ATSB also found that QR’s management oversight of the Citytrain driver MOC process did not include planned assurance activities or regular and effective auditing of how the MOC assessments were being conducted, even after there were multiple indications that the process could have been undermined by not being conducted as designed.

In addition to the safety issues associated with the AWS and the MOC process, the ATSB also identified safety issues with QR’s implementation of risk triggered commentary driving (RTCD) and the limited use of recorded data to determine driver compliance with key operational rules that had been designed to minimise the risk of SPADs on the Citytrain network.

What has been done as a result

QR has undertaken a range of actions to change the design and implementation of its train driver MOC process, and it has also undertaken a number of oversight activities focussing on the MOC process. In addition, it has undertaken a range of activities to improve the implementation and consistency of the application of RTCD, and the use of event recorders to monitor driver compliance with key operational rules.

There is limited potential to effectively redesign the AWS to reduce SPAD risk. However, QR is in the process of introducing the European Train Control System (ETCS) in parts of the south-east Queensland network, and this system, where and when it is implemented, will provide more sophisticated engineering controls for detecting potential SPADs and managing their risk.

Safety message

This investigation has highlighted the importance for rail organisations to have an assurance system in place that effectively monitors and reviews processes for maintaining and assessing the competence of rail safety workers. In addition, assurance activities must be suitably designed and implemented as designed, to ensure that they appropriately evaluate the controls that manage risk.

The rate that individual drivers pass a signal at danger is extremely low. Efforts to ensure reliable driver performance are necessary but need to be considered in the context that human error cannot be eliminated entirely. This occurrence has highlighted the importance for suburban passenger rail networks to have sophisticated engineering controls in place to detect potential or actual SPADs and manage their risk.

Even though SPADs are rare events for most drivers, the role of driver performance in minimising the risk of SPADs is obviously still critically important. This investigation provides an opportunity for train drivers to reflect on the need for crosschecking signal information, particularly at locations where there is potential for a signal read-through.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to RO-2018-002-SI-01 - Go to RO-2018-002-SI-02 - Go to RO-2018-002-SI-03 - Go to RO-2018-002-SI-04 - Go to RO-2018-002-SI-05 -

Train driver maintenance of competency assurance

Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements.

Safety issue details
Issue number: RO-2018-002-SI-01
Who it affects: Queensland Rail Citytrain rail traffic drivers
Status: Closed – Adequately addressed

Oversight of the train driver maintenance of competency process

Queensland Rail’s management oversight of the Citytrain driver maintenance of competency (MOC) process did not include planned assurance activities or regular and effective auditing of how the MOC assessments were being conducted, even after there were multiple indications that the process was not being conducted as designed.

Safety issue details
Issue number: RO-2018-002-SI-02
Status: Closed – Adequately addressed

Design of the automatic warning system (AWS)

The automatic warning system (AWS) provided the same audible alarm and visual indication to a driver on the approach to all restricted signals (that is, double yellow, yellow, flashing yellow and red aspects). The potential for habituation, and the absence of a higher priority alert when approaching a signal displaying a red aspect, reduced the effectiveness of the AWS to prevent signals passed at danger (SPADs). This placed substantial reliance on procedural or administrative controls to prevent SPADs, which are fundamentally limited in their effectiveness.

Safety issue details
Issue number: RO-2018-002-SI-03
Status: Closed – Partially addressed

Implementation of risk triggered commentary driving (RTCD)

After mandating the use of risk triggered commentary driving (in 2011) to mitigate the risk of signals passed at danger, Queensland Rail Citytrain did not provide the necessary support to its trainers, assessors and drivers to effectively maximise the potential benefits of the technique and minimise the potential limitations or risks associated with the technique.

Safety issue details
Issue number: RO-2018-002-SI-04
Status: Closed – Adequately addressed

Use of event recorders to monitor driver performance

Prior to the signal passed at danger (SPAD) occurrence in January 2018, Queensland Rail did not routinely and systematically analyse recorded data to determine driver compliance with key operational rules that had been designed to minimise the risk of SPADs.

Safety issue details
Issue number: RO-2018-002-SI-05
Status: Closed – Adequately addressed
General details
Date: 10 January 2018   Investigation status: Completed  
Time: 1038 AEST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Bowen Hills   Investigation phase: Final report: Dissemination  
State: Queensland    
Release date: 15 April 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train 1 details

Train 1 details
Line operator Queensland Rail  
Train operator Queensland Rail  
Train registration TP43  
Type of operation Suburban passenger service  
Sector Passenger - metropolitan  
Damage to train Nil  
Departure point Varsity Lakes Station, Qld  
Destination Brisbane Airport, Qld  

Train 2 details

Train 2 details
Line operator Queensland Rail  
Train operator Queensland Rail  
Train registration TR50  
Type of operation Suburban passenger service  
Sector Passenger - metropolitan  
Damage to train Nil  
Departure point Domestic Airport, Qld  
Destination Roma Street Station, Qld  
Last update 15 April 2021