Queensland Rail driver goes through red light during sneezing fit, signalling system constraints exposed
A Brisbane train driver has steered an inner city peak-hour service through a red light during a sneezing fit, triggering an investigation after it exposed “inherent constraints” in Queensland Rail’s signalling system.
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A Brisbane train driver with undiagnosed Covid steered an inner city peak-hour service through a red light.
The dangerous mistake did not set off a safety alarm, sparking calls from the transport safety investigator for Queensland Rail to conduct a risk review of warning systems.
On May 24, 2023, a passenger train was moving between the Fortitude Valley and Bowen Hills stations when the driver had a sneezing fit and passed a stop signal.
The driver, who later tested positive for Covid-19, saw the signal as they went through and hit the emergency brakes.
The train stopped 64m past the signal, and the driver made an emergency radio call to network control.
An Australian Transport Safety Bureau investigation later found the driver had acknowledged an automatic warning alert as the train approached the stop signal, but did not recognise it at stop, or later recalled acknowledging the alert.
The investigation also found that due to “inherent constraints” in Queensland Rail’s signalling system, the network control officer was not alerted to the incident by a Signals Passed at Danger (SPAD) alarm.
SPAD occurs when a train passes a stop signal without authority.
ATSB chief commissioner Angus Mitchell explained the investigation found Queensland Rail’s risk register for SPADs did not “assess the inherent constraints in the signalling system”.
“The ATSB considers a scenario where a SPAD alarm is not presented to the network control officer, and the driver is not aware of the SPAD, has not been considered in Queensland Rail’s risk assessments,” Mr Mitchell said.
The safety investigator recommended that Queensland Rail review the risk associated with a SPAD in these circumstances and consider any risk controls that may be appropriate.
“In most train-to-train collision scenarios, the accident is preceded by at least one train travelling through a stop signal,” Mr Mitchell said.
“Eliminating these SPAD events is therefore a key focus for rail industry participants, in particular operators, towards reducing the risk of accidents.”
Queensland Rail still had current risk control arrangements in place and a preferred engineering control of the European Train Control System (ETCS) technology would be implemented.
The same risk level would remain at Queensland Rail until the recommended ETCS technology was implemented, an advanced digital signalling system.
Currently being tested on the Shorncliffe line, the technology would be progressively rolled out across the SEQ rail network over the next 10-15 years.
“These types of limitations should be eliminated where possible,” Mr Mitchell said.
“Where that is not possible, the hazards they create should be considered in risk assessments related to SPAD and collision prevention.”
Queensland Rail Head of SEQ Neil Backer said every SPAD event is taken seriously and investigated.
“We acknowledge the report released by the Australian Transport Safety Bureau (ATSB) and want to reassure customers that SPAD prevention continues to remain a critical safety focus,” Mr Backer said
“Queensland Rail has several SPAD prevention initiatives implemented across the organisation, including a SPAD prevention taskforce, innovative technologies - such as the progressive implementation of European Train Control System (ETCS) and driver training, education, competency testing and awareness.
“Other initiatives include the adjustment to the volume of alert signals, upgrades to LED aspects of signals to improve sighting, installing additional warning signals and the updating of a SPAD risk management framework.
“Queensland Rail’s SPAD rate has continued to trend downwards for the past several months.”
Originally published as Queensland Rail driver goes through red light during sneezing fit, signalling system constraints exposed
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