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Output Number
RR20070033
Approval Date
Organisation
TransAdelaide
Published Date Time
Recommendation type
Recommendation
Mode
Rail
Date released

Safety Issue

It is possible that departure procedures at Adelaide station
could increase the risk of 'Starting Against Signal' SPADs due to
expectation error. Platform coordinators give RoW at the scheduled
departure time regardless of any delay to clearing the departure
signal. Under these conditions, it is possible that drivers would
move off and slowly approach the signal with an expectation that it
would clear as they approached increasing the risk of an error if
the signal remained red.

Safety Recommendation

The Australian Transport Safety Bureau recommends that
TransAdelaide undertake further work to address this safety
issue.

Organisation Response
Organisation
TransAdelaide
Response Text

TransAdelaide acknowledged that signal anticipation is a
potential cause of SPADs and have included the risk in their risk
management plan. TransAdelaide has also initiated SPAD awareness
programmes to educate drivers on the risks associated with signal
anticipation.

ATSB Response

The ATSB acknowledges TransAdelaide's pro-active approach to
SPAD mitigation associated with signal anticipation. However, since
TransAdelaide's investigation process was unlikely to have provided
a clear understanding of factors that may have contributed to past
SPADs, it is unlikely that the factors contributing to signal
anticipation could have been identified for all scenarios.

This issue is reflected in TransAdelaide's risk management plan
in which the recommended actions to control signal anticipation
risk is related to training programs and rigorous application of
performance management systems (treatments addressing human error
factors). If TransAdelaide considers why drivers anticipate a
signal clearing, further opportunities may be identified to control
the risk.

As mentioned previously, this observation only indicates that
the process was considered incomplete and does not indicate that
the outcome was incorrect in every case. TransAdelaide may identify
further opportunities to improve railway safety if it considers
this safety issue further.