Occurrence No: 2006003
Occurrence Date: 28 March 2006
BACKGROUND
At approximately 0700 on 28 March 2006, TransAdelaide train H307
passed signal 161 at Adelaide Station while displaying a red
indication.
The investigation team has been advised that train H307 was
positioned approximately 15 to 20 metres from signal 161 in
preparation for departure from Adelaide Station. In accordance with
TransAdelaide departure procedures, a Platform Coordinator was
positioned approximately 10 metres in front of the railcar to give
a "Starting" hand signal. The driver of train H307 then departed
the platform; however train H307passed signal 161 while a red
indication was displayed.
ANALYSIS
During early stages of the investigation the Australian
Transport Safety Bureau (ATSB) gathered evidence suggesting that a
number of factors contributed to train H307 passing signal 161
while displaying a red indication.
TransAdelaide's "Common General Operating Rules" (dated 22
November 2000) defines the "Starting" hand signal (i.e. guard's
signal to driver to start train) in rule 43(k). This rule states
that therequired signal is a "Green light waved above the
head…". However, the investigation has been advised that
Platform Coordinators indicate a "Starting" hand signal using a
steady green light held by an outreached horizontal arm. A steady
green light is defined in rule 43(m) as an "All clear or
proceed" signal which is equivalent to a clear or proceed line
side signal.
In addition to hand signalling methods that are inconsistent
with operating rules, it is likely that the position of the
Platform Coordinator and the outreached arm may have obscured, or
partially obscured, signal 161. Under these conditions it is
possible that the driver of train H307 only observed a green light
before departing the platform.
The ATSB is continuing its investigation. However, in view
of the evidence to hand the ATSB has made the following interim
recommendation under section 25 of the Transport Safety
Investigation Act 2003. Please note that this interim
recommendation in no way prejudges the final conclusions that may
be reached in the ATSB's final report into this accident.