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.
The ATSB recognises that Queensland Rail has ensured more focus is placed on safety change management is conducted as part of its operational readiness framework. The extent to which this will increase focus on safety change management processes when conducting changes such as the change to the allright procedure for station staff in January 2019 is unclear. Nevertheless, the ATSB recognises that the risk of this specific safety issue has decreased as guards and drivers have become more familiar with the new processes at suburban station platforms, and the rate of start against signal SPADs has decreased. The ATSB will continue to examine change management issues in current and future investigations.
In January 2022, Queensland Rail (QR) advised:
Queensland Rail has reviewed, consulted and implemented the revised Operational Readiness program that is governed by MD-17-447 [Framework: Operational Readiness]. As a part of this revision the operational readiness assessment process has been simplified and safety change management (MD-12-219) has been integrated into the assessment criteria. Further the operational readiness assessments are subject to centralised assessment processes that is governed and draws upon relevant subject matter experts including from Queensland Rail’s Safety Risk and Assurance team to finalise assessment ratings and to determine whether Operational Readiness assurance is required before the go live date.