The procedures and guidance documentation for authorising movement past signals displaying a Stop indication was ambiguous.
Mandating that NCO's complete a written Caution Order and the development of a new Standing Notice will better inform operators of track configurations, reducing the risk of a recurrence of this incident.
ARTC has mandated that network control officers complete a written Signalman's Caution Order form prior to verbally transmitting the instruction to the crew on all occasions when it is necessary to issue such an authority.
Australian Rail Track Corporation has developed a draft Standing Notice to supersede Standing Notices SN2533 (2008) and SN2529 (2009). The draft Standing Notice will contain the procedure for managing failure of points and the process for issuing an authority (Caution Order) to proceed past a signal that does not display a Proceed indication as expected. The draft Standing Notice will contain information of the 'End of Broad Gauge' signage and the DG/SG turnout indicators.
The Caution Order process will be amended to include the passing of dwarf signals that do not display a Proceed indication as expected.
The draft Standing Notice once approved will be distributed to all Operators and stakeholders.
The Australian Transport Safety Bureau is satisfied that the action proposed by ARTC will adequately address the safety issue.
