Adelaide Yard, South Australia, 24 February 2011 24 South Australia, Yard, Adelaide in and 215A trains G231 suburban passenger Collision between ATSB TRANSPORT SAFETY REPORT Rail Occurrence Investigation RO-2011-002 Final Collision between suburban passenger trains G231 and 215A in Adelaide Yard, South Australia 24 February 2011 RO-2011-002.indd 1 7/10/11 2:02 PM ATSB TRANSPORT SAFETY REPORT Rail Occurrence Investigation RO-2011-002 Final Collision between suburban passenger trains G231 and 215A in Adelaide Yard, South Australia 24 February 2011 Released in accordance with section 25 of the Transport Safety Investigation Act 2003 - i - Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office: 62 Northbourne Avenue Canberra, Australian Capital Territory 2601 Telephone: 1800 020 616, from overseas +61 2 6257 4150 Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117, from overseas +61 2 6247 3117 Email: [email protected] Internet: www.atsb.gov.au © Commonwealth of Australia 2011 In the interests of enhancing the value of the information contained in this publication you may download, print, reproduce and distribute this material acknowledging the Australian Transport Safety Bureau as the source. 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ISBN and formal report title: see ‘Document retrieval information’ on page v - ii - CONTENTS THE AUSTRALIAN TRANSPORT SAFETY BUREAU ................................ vii TERMINOLOGY USED IN THIS REPORT ................................................... viii EXECUTIVE SUMMARY ................................................................................... ix 1 FACTUAL INFORMATION ........................................................................ 1 1.1 Overview .............................................................................................. 1 1.2 Location ................................................................................................ 1 1.3 Train information .................................................................................. 2 1.4 Train control and Adelaide station personnel ....................................... 3 1.5 Signalling system .................................................................................. 4 1.6 The occurrence ..................................................................................... 5 1.6.1 Post occurrence .......................................................................... 7 2 ANALYSIS ...................................................................................................... 8 2.1 Sequence of events analysis ................................................................. 8 2.2 Examination of signal data ................................................................. 12 2.3 Train handling .................................................................................... 13 2.4 Departure procedure - Adelaide Station ............................................. 14 2.5 Factors influencing driver actions ...................................................... 14 2.5.1 Summary of factors influencing driver actions ........................ 18 2.6 History of SPADs - Adelaide Station ................................................. 19 2.7 Signal Passed at Danger (SPAD) - general ......................................... 20 2.7.1 SPADs - Physical risk controls ................................................ 21 2.7.2 SPADs - Human factor management ....................................... 22 3 FINDINGS ..................................................................................................... 29 3.1 Context ............................................................................................... 29 3.2 Contributing safety factors ................................................................. 29 3.3 Other safety factors ............................................................................. 29 3.4 Other key findings .............................................................................. 30 4 SAFETY ACTION ........................................................................................ 31 4.1 Public Transport Services ................................................................... 31 4.1.1 Dispatching trains towards starting signal ............................... 31 4.1.2 Vigilance control ..................................................................... 32 - iii - 4.1.3 SPAD Investigation Form ........................................................ 32 4.1.4 Driver training ......................................................................... 33 4.1.5 Interactive driver training ........................................................ 33 4.1.6 Inconsistencies between RoW procedures ............................... 34 4.1.7 Inconsistencies between Work Instructions and the Common General Operating Rules .......................................... 34 4.1.8 Fatigue management ................................................................ 35 APPENDIX A: SOURCES AND SUBMISSIONS ............................................. 36 APPENDIX B: SIGNALLING AND POSITIVE TRAIN CONTROL ........... 38 APPENDIX C: SPAD STATISTICS/GRAPHS ................................................. 40 - iv - DOCUMENT RETRIEVAL INFORMATION Report No. Publication date No. of pages ISBN RO-2011-002 October 2011 50 978-1-74251-210-5 Publication title Collision between suburban passenger trains G231 and 215A in Adelaide Yard, South Australia 24 February 2011 Prepared by Reference Number Australian Transport Safety Bureau ATSB- Oct11/ATSB25 PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au Commissioned by Office of the Rail Safety Regulator GPO Box 1533 Adelaide SA 5001 Acknowledgements Other than for the purposes of copying this publication for public use, the map information section may not be extracted, translated, or reduced to any electronic medium or machine readable form for incorporation into a derived product, in whole or part, without prior written consent of the appropriate organisation listed above. This investigation report was commissioned and funded by the Office of the Rail Safety Regulator and the Government of South Australia. Abstract At 1209 on 24 February 2011 a suburban commuter train (215A) with 17 passengers on board was being routed from the Up South Main Line into platform 5 at the Adelaide Station. At about the same time a second commuter train (G231) with 22 passengers on board that was departing the Adelaide Station passed signal 141 located at the end of platform 3 at low speed. Shortly thereafter both drivers realised that their trains would come into conflict and applied their train brakes but it was too late to avoid a collision. There were no injuries as a result of the collision; however, both trains sustained minor damage. The ATSB established that the driver of train G231 received a ‘yellow’ Right of Way flag from the Platform Coordinator, indicating that platform work was complete and that the train could advance up to signal 141 which was displaying a stop (red) indication. It was concluded that as the train approached signal 141 the driver diverted his attention onto a lesser task of checking train notices and did not concentrate on the more important task of observing the status of signal 141. Subsequently he perceived that signal 141 had changed to a ‘proceed’ aspect, although the investigation subsequently established that it did not clear at any stage prior the SPAD event and continuously displayed a stop (red) indication for the passage of train G231. In the interests of enhancing future rail safety the ATSB identified a number of safety issues which included the dispatching of trains towards starting signals, the level of protection afforded by the train’s dead man’s control and Automatic Warning System and a range of opportunities to reduce the risk of human performance error. The ATSB is satisfied that the actions proposed in response by Public Transport Services adequately address each of the safety issues. - v - - vi - THE AUSTRALIAN TRANSPORT SAFETY BUREAU The Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory agency. The Bureau is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in: independent investigation of transport accidents and other safety occurrences; safety data recording, analysis and research; fostering safety awareness, knowledge and action. The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and Regulations and, where applicable, relevant international agreements. Purpose of safety investigations The object of a