Investigation into emergency stop at Bowen Hills train station

Two Brisbane passenger trains narrowly avoided a serious collision at a busy inner-city train station after a driver misread a signal, an investigation has found.

Two passenger trains narrowly avoided a very serious collision on an inner Brisbane line after a driver misread a yellow light for a green and cancelled an automated warning alarm.

Train operators were forced to issue an emergency stop command after a train en route to Brisbane Airport passed through a red signal and stopped just 126 metres short of potential collision point.

A report of the investigation into the near miss at Bowen Hills Train Station on January 10, 2018 was made public today by the Australian Transport Safety Bureau.

It found that a Citytrain departed Bowen Hills station when a departure signal was displaying a yellow light, meaning the subsequent signal would be set at red.

The driver mistook the first signal for green and continued to drive the train forward.

Approaching the second signal, an automatic warning system generated an alarm in the train driver cab, indicating the signal was in danger, which, if the driver did not acknowledge, would have triggered an emergency brake application.

The driver departed Bowen Hills station, mistaking the yellow signal for a green. Picture: supplied

But the driver pressed the reset button, in what investigators described as a “reflexive response” and did not result in the driver effectively checking the second signal.

The train passed the second red signal, which generated an alarm at Queensland Rail management centre, resulting in a network control officer broadcasting an emergency stop command to the driver.

The driver stopped the train 126 metres short of a crossover and potential conflict point, where another passenger train bound for Roma St had just cleared.

“Had the NCO not issued the stop instruction, there was potential for a collision with another suburban train,” the report found.

The ABSB investigation found the immediate reason for the ‘Signal Passed at Danger’ (SPAD) was that the driver perceived the signal was displaying a green aspect and drove according to that belief.

“Such a ‘completely missed’ SPAD can have very serious consequences as there were limited risk controls or defences in place on the Queensland Rail (QR) Citytrain rail network to recover from the situation,” the report said.

The investigation also identified issues with the automatic warning system.

“Citytrain drivers frequently encounter restricted signals, and so it is understandable how drivers can become conditioned to cancelling the automatic warning system alarm as a habitual, reflexive reaction,” ATSB Director Transport Safety Dr Mike Walker said.

The report follows revelations by The Courier-Mail that the rate of red lights being run on Queensland’s rail lines is climbing.

The driver then proceeded through a second signal, with a red light, which generated an alarm at Queensland Rail management centre, resulting in a network control officer (NCO) to broadcast an emergency stop command to the driver. Picture: supplied

There were 33 SPAD events in the last 9 months of 2020 – or nearly one a week – but the rate is even higher now.

The ATSB said Queensland Rail had undertaken a range of actions to change the design.

They have also undertaken a range of activities to improve the implementation of its train driver maintenance of competency process and risk triggered commentary driving.

“The rate that individual drivers pass a signal at danger is extremely low,” the report said.

“Even though SPADs are rare events for most drivers, the role of driver performance in minimising the risk of SPADs is obviously still critically important.

“This investigation provides an opportunity for train drivers to reflect on the need for crosschecking signal information, particularly at locations where there is potential for a signal read-through.”