Safety Issue

The automatic warning system (AWS) provided the same audible alarm and visual indication to a driver on the approach to all restricted indications. 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 usefulness.

Response by Queensland Rail

On 11 April 2025, Queensland Rail reported to the ATSB that it has taken the following safety initiatives to address the issue of potential habituation and the lack of higher priority alert tone/volume for red signals in automatic warning systems (AWS), which can reduce their effectiveness in preventing signal passed at danger (SPADs):

• Progressive implementation and rollout of European Train Control System (ETCS). At present ETCS is being implemented on the Queensland Rail's Shorncliffe Pilot line undergoing verification, validation and certification. ETCS rollout is in the design phase for other parts of QR Network.
• Auditory volume of AWS for restricted signals versus green signals have been adjusted for better auditory discrimination, which is consistent with the approach taken by other jurisdictions nationally and globally.
• Queensland Rail operation’s area has implemented comprehensive and enhanced driver training focusing on driver route knowledge of track gradients, adhesion levels, and train braking characteristics to help drivers make better judgements about when to start braking in relation to signal aspects.
• Improved accident investigation and analysis, route and signal design management through the Signal Sighting Committee assessment.
• Exploration of advanced driver rostering through the use of the Fatigue Assessment Tool by InterDynamics to consider improvements.
• Active participation in development groups for The Rail Industry Safety and Standards Board (RISSB). This includes the Rail Vigilance Timing Cycles Code of Practice and Australian Standard AS 7475 Management of SPADs and Proceed Authority Exceeded Events.
• Reviewing Risk Triggered Commentary Driving (RTCD) standard and related training to explicitly include the AWS Restricted alarm as a ‘risk trigger’ to commence RTCD.
• Embedding non-technical skills of situational awareness, decision‑making and threat and error management in the verification of competency process.

Update of project by Department of Transport and Main Roads 

On 10 April 2025, the ATSB requested Queensland Department of Transport and Main Roads (TMR), as the project sponsor of ETCS Level 2 program, provide information on the anticipated implementation schedule of the program for the Queensland Rail network.

On 28 April 2025, TMR responded that there is a long-term plan to deploy ETCS throughout the entirety of the South East Queensland (SEQ) rail network. Deployment is occurring in stages and full deployment will take many decades. Numerous factors are considered to determine which stages are to be prioritised. Operationalisation of ETCS requires the SEQ rail network to be sectorised, with Sector 1 being the priority. Sector 1 is the north‑south corridor joining the Gold Coast and Sunshine Coast through the Brisbane CBD.

Cross River Rail (CRR) (twin tunnels under the Brisbane River, exiting in the vicinity of Exhibition on the northside and Dutton Park on the southside) is the first ETCS deployment funded and currently under construction. CRR also deploys ETCS overland from the southern tunnel portal to Moorooka Station, plus the Shorncliffe Pilot Line from Nudgee to Shorncliffe. The Shorncliffe Pilot Line is anticipated to be in revenue service by the end of 2025. The sections between Beenleigh and Varsity Lakes are also in delivery and are expected to be in revenue service by the end of 2026. Further sections have been funded but are not yet in delivery including a new spur line, the Direct Sunshine Coast Rail Line (Beerwah to Birtinya), Elimbah to Beerwah, and Kuraby to Beenleigh.

Although yet to be funded, the sections from Moorooka to Kuraby, and from Elimbah to Northgate are in planning with the desire to have virtually the entirety of Sector 1 (coast to coast) in revenue service by 2032. Subsequent deployments are anticipated but not yet in planning, with Sector 2 (from Ipswich to Shorncliffe) the likely next sector for ETCS deployment based upon the volume of services on that line.

The TMR response identified priority sectors of the SEQ network planned for ETCS Level 2 implementation. Bowen Hill Station and surrounding areas were in sector 2 (Shorncliffe, Domestic Airport, Doomben, Springfield, Rosewood lines) and sector 3 (Ferny Grove and Cleveland line). 

ATSB comment

The ATSB notes the response by Queensland Rail and the actions taken in relation to the prevention of signal passed at danger occurrences. While welcome, these actions do not address the identified issue.

However, the ATSB also acknowledges the substantial difficulty in widespread modification of the AWS technology to distinguish between the alerts that occur in response to signals with a red aspect compared to other restricted signals. Additionally, Queensland Rail is reliant upon the implementation of ETCS Level 2 across the South East Queensland network to replace AWS technology, which will take many years.

As such, the safety issue will be closed as not addressed.

While that means that the risk associated with the identified constraint of the AWS remains, safety action taken in response to safety issue RO‑2023‑004‑SI‑01 provides an opportunity to mitigate both issues.