Rail safety investigations & reports

Signal DP29 passed at danger involving suburban passenger train DW17 and near collision with another suburban passenger train Park Road Station, Queensland, on 25 March 2019

Investigation number:
RO-2019-009
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On 25 March 2019, a suburban passenger train (DW17), operated by Queensland Rail (QR) Citytrain, exceeded its limit of authority by passing signal DP29 at Park Road Station, Brisbane, while it displayed a stop indication. The signal passed at danger (SPAD) occurrence resulted in a near collision with another suburban passenger train (1E65), which was proceeding in the same direction on an adjacent line to a merging conflict point.

The potential of collision was prevented by the actions of a tutor driver in the driving cab of 1E65, and a network control officer who transmitted an emergency stop command after receiving a SPAD alarm. DW17 exceeded its limit of authority by 305 m and stopped 55 m past the conflict point, while 1E65 stopped about 70 m prior to the conflict point. There were no injuries, however DW17 ran through the points, which were set for 1E65, resulting in minor infrastructure damage.

What the ATSB found

After DW17 stopped at Park Road, with the platform departure signal (DP29) displaying a stop indication, the driver did not apply the operator's ‘stopped at a red’ procedure. After receiving the allright signal from station staff indicating station duties were complete, the train’s guard promptly provided the driver with the rightaway signal, even though the departure signal was still displaying a stop indication. The driver then promptly departed the station platform without effectively checking and confirming the departure signal. The actions of the guard and the driver were probably associated with a very high level of expectancy that, after receiving the allright signal and the rightaway respectively, the departure signal was indicating a proceed aspect.

The occurrence involved a new generation rollingstock (NGR) train. In contrast to previous QR suburban passenger trains, where the guard was positioned in the middle, the NGR had the guard positioned at the rear, and station staff provided assistance (if required) to passengers who were boarding or alighting in the middle of the train. The NGR fleet commenced operations in December 2017, and in January 2019 there was a change to procedures that required station staff at suburban stations to provide the allright signal for all NGR services. This significantly increased the frequency that allright signals were provided to guards of NGR trains at suburban stations.

Following this change there were 5 start against signal SPADs involving NGR trains at suburban platforms between March 2019 and March 2020, with a sixth SPAD in April 2021. The investigation found that there were limitations in QR’s application of risk management and change management processes relevant to the introduction of the NGR that increased the risk of a start against signal SPAD. Specifically, multiple processes did not effectively consider the risk of station staff at suburban platforms providing the allright signal for all NGR trains even when the platform departure signal displayed a stop indication, which was in contrast to how allright signals were being provided in practice for all trains at the 3 central business district stations and 2 other designated stations.

At station platforms where a guard could not sight the departure signal, signal aspect indicators (SAIs) were installed. With the introduction of the NGR, with the guard at the rear of the train, a significant number of SAIs had to be installed or moved. The investigation found that QR’s procedures for the installation of SAIs did not provide sufficient guidance to ensure their consistent and conspicuous placement at station platforms. This problem, combined with an SAI’s non-salient indication when the platform departure signal displayed a stop indication, increased the risk that an SAI would not be correctly perceived by a train guard.

Although not a contributing factor, the investigation found that, associated with a late-notice roster change, the guard was probably experiencing a level of fatigue known to adversely influence performance. In addition, QR’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes.

What has been done as a result

QR advised that it had reviewed, consulted and implemented a revised Operational Readiness program, which involved simplifying the operational readiness assessment process and integrating safety change management into the assessment criteria for future projects. The ATSB notes that, with regard to the issues associated with the change to the allright procedure, the risk of this specific safety issue has decreased as guards have become more familiar with the location of signal aspect indicators and the new processes at suburban station platforms. This has seen a decrease in the rate of start against signal SPADs in recent times. The ATSB will continue to examine change management issues in current and future investigations.

In addition, QR also issued an important safety notice to rail traffic crew and rostering personnel regarding unplanned shifts and required that rostering personnel complete a checklist when arranging unplanned shifts with less than 12 hours notice prior to the start of the shift. QR also will review its fatigue risk management standard later in 2022.

Safety message

Where there are limited engineering controls to manage SPAD occurrences, it is vital that train drivers and guards routinely apply the procedures designed to minimise the risk of a SPAD. This is particularly important during the station dispatch process, when expectancies and distractions have been demonstrated to have undesired influences on performance.

Rail operators are reminded to apply structured risk management and change management processes. In particular, operators should apply a formal change management process to assess the potential risk of a procedural change before determining that the change is minor in nature. Operators also should ensure they understand the undocumented or informal risk controls that are in place in their operation, and how exactly operational personnel are applying current procedures, prior to introducing changes.

A commonly-overlooked aspect of risk management is the need to consistently monitor and review the health of risk controls, either existing or newly-introduced, through a variety of activities and to continuously look for opportunities to improve the operator’s risk position.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Glossary

Sources and submissions

About the ATSB

Update

The ATSB systemic investigation into the SPAD involving DW17 at Park Road Station on 25 March 2019 is nearing completion. During the course of the investigation, five other similar start against signal SPADs at suburban station platforms occurred on the Citytrain network and they were examined as part of the ATSB investigation.

In addition to the specific factors associated with the 25 March 2019 SPAD, the investigation considered a range of topics, such as the location and design of signal aspect indicators (SAIs), and processes associated with risk management, change management and fatigue management.

The investigation and draft report underwent an internal review process to ensure the findings adequately and accurately reflect the analysis of available evidence. The draft report was sent to all directly involved parties on 29 October 2021 for comment. The final report is expected to be finalised and published in Q1 2022.

Summary

The ATSB is investigating a signal passed at danger (SPAD) incident at Park Road Station in Brisbane, Queensland, on 25 March 2019.

Queensland Rail (QR) suburban passenger train DW17 (Cannon Hill to Northgate), running on the Down Southern Suburban line, performed a normal station stop at Park Road. After passengers had boarded and the doors had been closed, the guard provided the 'rightaway' signal to the driver.

At this time, signal DP29, located at the end of Park Road platform, displayed a red aspect. Train DW17 departed at 1216, passing signal DP29 at danger and exceeding its authority.

Signal DP29 was displaying a red aspect because another suburban passenger train 1E65 (Beenleigh to Ferny Grove) was running in the same direction through Park Road Station, on the parallel Middle Road.

The Down Southern Suburban line and the Middle Road converge at the 643A/B points, located approximately 230 m from the station, just before the rail bridge over Annerley Road. The points had been set to allow train 1E65 to move from the Middle Road to the Down Southern Suburban line, and run ahead of train DW17.

On advice from the network control officer, trains DW17 and 1E65 stopped. By this time, train DW17 had run through the 643A/B points.  

As part of the investigation, the ATSB will interview the crews of both trains, and review video footage, train event recorder data and information from QR's Rail Management Centre.

A final report will be released at the end of the investigation.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

 

Safety Issues

Go to RO-2019-009-SI-003 - Go to RO-2019-009-SI-001 - Go to RO-2019-009-SI-004 -

Risk management associated with changing allright signal procedures for the NGR

Limitations in Queensland Rail’s application of risk management and change management processes relevant to the introduction of the new generation rollingstock (NGR) increased the risk of a start against signal SPAD (signals passed at danger). Specifically, multiple processes did not effectively consider the risk of station staff at suburban platforms providing the allright signal for all NGR trains even when the platform departure signal displayed a stop indication, which was in contrast to how allright signals were being provided in practice for all trains at the 3 central business district stations and 2 other designated stations.

Safety issue details
Issue number: RO-2019-009-SI-003
Status: Closed – Adequately addressed

Placement of signal aspect indicators at station platforms

Queensland Rail's process for the installation of signal aspect indicators (SAIs) did not provide sufficient detail to ensure consistent and conspicuous placement of SAIs at station platforms. This problem, combined with an SAI’s non-salient indication when the platform departure signal displayed a stop indication, increased the risk that an SAI would not be correctly perceived by a train guard.

Safety issue details
Issue number: RO-2019-009-SI-001
Status: Closed – Partially addressed

Management of late-notice roster changes

Queensland Rail’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes.

Safety issue details
Issue number: RO-2019-009-SI-004
Status: Open – Safety action pending
General details
Date: 25 March 2019   Investigation status: Completed  
Time: 1215 AEST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Park Road Station, Brisbane   Investigation phase: Final report: Dissemination  
State: Queensland    
Release date: 29 March 2022   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Queensland Rail  
Train operator Queensland Rail  
Train registration DW17  
Type of operation Suburban passenger service  
Sector Passenger - metropolitan  
Damage to train Minor  
Departure point Cannon Hill, Queensland  
Destination Northgate, Queensland  
Last update 29 March 2022