Prior to the signal passed at danger (SPAD) occurrence in January 2018, Queensland Rail did not routinely and systematically analyse recorded data to determine driver compliance with key operational rules that had been designed to minimise the risk of SPADs.
The ATSB acknowledges the significant increase in activity that Queensland Rail (QR) has undertaken in this area since 2017. Although the ATSB notes that there are some limitations with the data for measuring compliance rates with some SPAD mitigation rules, the ATSB is satisfied that the action undertaken by QR has reduced the risk of this safety issue, and that the risk of this safety issue would be further reduced with the introduction of automatic event recorder analytics software
As stated in the ATSB investigation report, in October 2017 Queensland Rail (QR) established a SPAD Prevention Taskforce. QR advised that the taskforce ‘brought together key employees from across Queensland Rail to deliver a comprehensive SPAD strategy and a broad range of new safety controls focused on human factors, driver behaviour and increased level of engagement with our staff’.
The taskforce identified the use of proactive event recorder analysis as one of its critical SPAD prevention initiatives. After a period of planning, baseline data collection commenced in April 2018. The data collection was based on four SPAD mitigation rules (Citytrain driving procedures):
In February 2019, QR advised that:
A proactive review program is in place that analyses the train event recorders of key SPAD avoidance driving methodologies:
- Lead indicator that provides visibility of driving behaviours across the organization
- Enables direct and timely feedback to drivers on driving behaviour/technique.
As of March 2019, QR was still collecting baseline data.
In March 2021, QR advised of the following update regarding its safety action on this topic:
QR has put in place proactive monitoring of event recorders within excess of 16000 reviews completed. This provides detailed insights to support coaching and mentoring to train crew and information to improve training.
QR … also completes in-cab monitoring in respect to the required driving methodologies across the network. Coaching and skill development is provided where necessary. QR is currently exploring the feasibility of implementing an automatic event recorder analytics software service as part of our SPAD Prevention strategy.
