Safety issue

Safety issue description

The rule describing the required driver response to a Distant signal at Caution in a two-position signalling system did not fully reflect the signalling system design principles. 
Issue number RO-2015-009-SI-02
Issue owner V/Line
Transport function Network Operations
Date issue released 12/12/2016
Issue status justification

V/Line has not yet finalised its response to the safety issue.

Safety action

Action type Recommendation
Action number RO-2015-009-SR-029
Organisation V/Line
Action date 12/12/2016
Action description

That V/Line amends the rule for the required driver response to a Distant signal at Caution. The amendment should bring the rule into alignment with the signalling system design principles.
Action status Closed

Organisation response

Date received 20/09/2017
Organisation V/Line
Response status Closed
Response text

V/Line has amended Rule 5 Section 2 (distant signals). 

Safety action

Action type Proactive action
Action number RO-2015-009-NSA-028
Organisation V/Line
Action date 12/12/2016
Action description

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised by V/Line of the following additional safety actions in response to this occurrence:

  • On 19 June 2015, a 70 km/h speed restriction was introduced for Up (Geelong-bound) traffic approaching Marshalltown level crossing.  
  • On 22 June 2015, V/Line issued a notice to drivers advising of the SPAD incident and lessons learned.
  • On 4 September 2015, a 40 km/h speed restriction was also introduced for Down trains approaching Marshall Station.
  • The driver underwent a detailed return to work plan that included a two-position signals theory and assessment, and an extended period of safety audits.
  • SPAD investigation findings recommended a three-position signalling upgrade for the Geelong - Waurn Ponds section of track. Subsequently, the 2016-17 Victorian State budget has funded the Business Case Development and Feasibility Study for Track Duplication South Geelong - Waurn Ponds.
Action status Released