After mandating the use of risk triggered commentary driving (in 2011) to mitigate the risk of signals passed at danger, Queensland Rail Citytrain did not provide the necessary support to its trainers, assessors and drivers to effectively maximise the potential benefits of the technique and minimise the potential limitations or risks associated with the technique.
The ATSB notes the safety action already undertaken and being undertaken to clarify the requirements of RTCD and facilitate more consistent application of the technique, and to simplify some of the recommended word strings. The ATSB still has concerns regarding potential problems with the mandatory nature of the technique in all situations. However, overall the ATSB is satisfied that the safety action undertaken and being undertaken will reduce the risk of this safety issue.
The Queensland Rail (QR) internal safety investigation into the 10 January 2018 SPAD occurrence at signal ME45 was completed in February 2018. The report included the following conclusions related to risk triggered commentary driving (RTCD):
There [is] currently no methods available for the monitoring of RTD’s compliance with RTCD requirements when alone in the driving cab.
Although the Relief RTD was deemed competent in his use and knowledge of RTCD during his Maintenance of Competency Assessment the Relief RTD stated during interview that he routinely does not use RTCD.
The report also included the following internal recommendation (with a due date of 30 November 2018):
Manager Train Services Delivery Training to lead a multidisciplinary review of Risk Triggered Commentary Driving to include (not exclusively) benchmarking, RTD consultation and feedback on the use of RTCD, training materials and methods, the use of RTCD as a training tool and methods to measure ongoing compliance, and produce an action plan to address any outcomes of the review.
In March 2021, QR advised the ATSB that the requirements for RTCD techniques were reviewed and updated to provide clarity on requirements. More specifically, it advised:
In December 2019, the review of Risk Triggered Commentary Driving was completed and MD-13-165 TSD Professional Driving – Risk Triggered Commentary Procedure was subsequently updated in May 2020.
An Important Operational Notice from Senior Manager TSD was emailed to all SEQ RTC on the 13 May 2020 detailing the new changes to Risk Triggered Commentary Driving (RTCD). These changes include:
- Amended verbalisation examples to reflect updated RTCD requirements
- Expanded RTCD trigger dot points, e.g. when observing “Check AWS” signs/signal distance marker signs
- RTCD mandatory requirements (2.3) now specifically includes incorporating the status of level/pedestrian crossings; encountering temporary speed restrictions (TSRs); and upon sighting restricted signals in non AWS territory into RTCD verbalisation requirements
- A new section (2.4) containing illustrated examples of using RTCD.
An indicative video example demonstrating the updated RTCD was placed on Traincrew SPAD Management Site to demonstrate the updated RTCD on the Ferny Grove Line.
The 12/24 Month Observations from the MOC cycle will be used as an opportunity to identify any RTC lacking the proper understanding of RTCD requirements by:
- Providing immediate feedback and/or coaching where minor re-calibration is required.
- Directing RTD to RTCD DVD and associated guidance materials
- Arranging for further in-depth RTCD coaching where significant gaps persist.
TSD are currently in the process of recalibrating the Tutor Drivers to ensure there is consistency in the way Trainee RTD are being taught RTCD. They have also published a revision checklist for the Trainees to use prior to them submitting the Summative Assessment.
