Executive summary
At 0738:061 on 20 September 2004 train 8868 passed signal FS66 when it was displaying a stop aspect. Train 8868 was a freight train from central Queensland bound for Fisherman Islands and was crewed by a driver who had signed on at Maryborough at 0050 the same day. Signal FS66 is about five kilometres from Fisherman Islands and about 100 metres from a busy road crossing at Pritchard Road.
Train 8868 reached Lytton Junction at about 0736 and was routed onto the Fisherman Islands branch line for the final section of the journey. The driver recollects passing through this junction and setting one of the train radios to the Fisherman Islands local control channel. He thinks he then fell asleep, as he remembers little until sensing that the train was travelling too slowly. The driver then applied full power until about 15 metres from signal FS66, by which time the train was travelling at 49 km/h. Being momentarily unaware of where he was, applying full power, noticing the cars on the level crossing before realising (when 15 metres away) that the signal was red, indicate only a partial state of arousal. A service rate reduction2 of the brake pipe failed to stop the train from passing the signal and proceeding through the Pritchard Road crossing. Because of the rate of reduction and because the brake pipe pressure reduced to 229 kPa, well below the 350 kPa equalised pressure of a full service application, it is concluded that the brake handle was placed in the ‘handle out’ position and not in the emergency position. The ‘handle out’ position is the notch immediately before the emergency position.
As train 8868 passed signal FS66 the protection cycle for the level crossing was only partially complete and the boom barriers were not horizontal. Train 8868 stopped about 175 metres beyond signal FS66 and 74 metres beyond the level crossing.
The emergency response to passing FS66 on a red signal was initiated by the driver, who radioed the Mayne train control centre to tell them what had happened. The Mayne train controllers had no indication of what aspect signal FS66 was displaying, or whether the SPAD3 had occurred, as this signal was controlled by the area coordinator at Fisherman Islands. The area controller at Fisherman Islands did receive a SPAD alarm at his workstation but had not responded to it by the time the Mayne train controller called. Train 8868 remained across the level crossing for nearly 40 minutes until a relief driver arrived and moved the train.
The investigation found that the driver of train 8868 was probably experiencing microsleep episodes on the approach to signal FS66 and that this was the principal contributing factor in this incident. The investigation was unable to determine if this fatigue was ‘personally induced’ or ‘task induced’.
The investigation also found that the interface procedures between the Mayne train control centre and Fisherman Islands local control in combination with the structure of the Fisherman Islands area coordinator/station officer’s role have the potential to inhibit emergency response. Additionally, the lack of certain track and train secondary protection devices was considered to be an absent defence.
Safety actions recommended as a result of this investigation include the drafting of a fatigue management standard/policy, evaluation of secondary wayside safety devices, emergency procedure amendments, interface procedure amendments, training in these procedures and a review of attendance at the Fisherman Islands area coordinator/station officer workstation.
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1 0738:06 – Eastern standard time synchronised as described at section 2 of this report.
2 Service rate reduction – brake-pipe air vented to atmosphere at a controlled rate to apply consistent propagation throughout the length of the train.
3 SPAD – An acronym common to the rail industry that stands for ‘Signal Passed at Danger’.
Recommended Safety Actions
As a result of its investigation, the ATSB makes the following recommendations with the intention of improving railway operational safety. Rather than provide prescriptive solutions, these recommendations are designed to provide guidance to interested parties on the issues that need to be considered. Recommendations are directed to those agencies that should be best placed to action the safety enhancements intended by the recommendations, and are not necessarily reflective of deficiencies within those agencies.
RR20050036
The ATSB recommends that QR compile a fatigue management policy/standard to guide managers and workers in how to manage fatigue in planning and operational situations. This policy/standard should also provide guidance on how to deal with reported instances of fatigue.
RR20050037
The ATSB recommends that QR evaluate the installation of wayside secondary protective/prompt device/s in advance of signal FS66. Such device is to be compatible with all operators. This recommendation is made in light of the position of FS66 and the number of SPADs that have occurred at this signal.
RR20050038
The ATSB recommends that QR amend the emergency response procedures applicable to Fisherman Islands to ensure that initial notification of a SPAD is sent to the officer who has control of the signal in question.
RR20050039
The ATSB recommends that QR amend the interface procedures between Mayne train control centre and Fisherman Islands with the intention of ensuring that all trains are contactable by the Fisherman Islands area controller/station officer when in signalled territory controlled by the Fisherman Islands area coordinator/station officer. Boundaries of signalled territory should be clearly defined and current discrepancies in regard to radio channels and signal control should also be amended.
RR20050040
The ATSB recommends that QR undertake training of all concerned in regard to emergency response and interface procedures between the Mayne train control centre and Fisherman Islands.
RR20050041
The ATSB recommends that QR examine methods of ensuring continued attendance by appropriately qualified employees at the Fisherman Islands area coordinator/station officer workstation.
RR20050042
The ATSB recommends that the Queensland Railway Safety Regulator actively monitor the actions initiated by QR in response to this investigation.