Queensland Rail did not have any restrictions on the distance or time that controlled speed could be used as a risk control for safe train operation in situations such as a condition affecting the network (CAN). The effectiveness of controlled speed has the significant potential to deteriorate over extended time periods due to its effect on driver workload, vigilance, fatigue and risk perception.
The ATSB recognises the difficulties in developing specific procedures for the use of controlled and restricted speeds to suit all situations, and also recognises the role that rolling stock operators need to play in managing the risks associated with using such speeds. The ATSB is satisfied that the safety action undertaken will reduce the risk associated with this safety issue.
In June 2020, in response to the draft ATSB report, Queensland Rail advised:
Queensland Rail liaised with other rail traffic operators who use the Queensland Rail network to develop a clear understanding of the requirements of RTCs [rail traffic crews] when receiving instructions to operate at Controlled Speed.
Additionally, the updated “MD-18-20” [Condition affecting the Network (CAN) Management] procedure requires the NCO to confirm with RTC their understanding of “Controlled Speed”.
Queensland Rail human factors and technical subject matter experts undertook a detailed review into the application of controlled speed on the Queensland rail network.
The review concluded that due to the complex interactions between a vast number of performance shaping factors, a ‘one size fits all’ solution such as a blanket ban on the use of controlled speed was is unlikely to be suitable across the many possible operational contexts and conditions experienced on the network. These factors included (but were not limited to):
• The environment (e.g. rainfall, daylight / night-time running, line of sight, gradient etc.)
• Locomotive and rollingstock characteristics (e.g. braking performance, loco class, weight etc.)
• Human Factors (route knowledge, experience, workload, risk perception, non-technical skills etc.)
Furthermore (and notwithstanding the significant amount of research on driver behaviour for road vehicles), there is a lack of scientific research that has looked at the reasons for noncompliance and speeding related infringements for train drivers operating under controlled speed. This makes an evidence-based decision regarding a specific time or distance restriction difficult to establish, and industry benchmarking does not appear to provide a clear or consistent position supporting the adoption of such restrictions.
Building on the changes introduced by MD-20-53 [Instruction – Regional Network Operational Status], Queensland Rail intends to review MD-18-20 to update and integrate seamlessly with MD-20-53 and following consultation with relevant above rail operators seek to integrate further information that guides the use and conditions around controlled speed vs restricted speed and communication frequency between network control and rail traffic crew including relevant enquiry by network controllers into how the rail traffic crew are managing other human factors issues within the driving cab i.e. rotation and rest breaks.
In June 2024, Queensland Rail (QR) advised that the review of the MD-18-20 procedure (Supply chain north – condition affecting the network (CAN) management) had previously been conducted. This review involved subject matter expert input from network operations north, rail safety and the human factors team to provide content changes.
Changes from the version at the time of the accident (January 2018) to the current version (February 2024) included:
QR also advised that MD-20-53 was withdrawn and replaced with a Network-Wide Operational Status Standard MD-22-233. This changed happened in March 2023 in response to the Traveston derailment. The new document incorporated many elements of MD-20-53 (including the traffic light system) but also includes specific ‘red’ triggers, with several relating specifically to water/flood hazards.
QR further advised that, following a recent review, MD-18-20 was to be withdrawn and replaced by MD-24-87 (Regional operations - conditions affecting the network management). This new document will become the overarching CAN management document for all regional operations and support specific procedures and process for the differing geographic locations, as well as capturing those procedures which are inherent to both control regions.
The ATSB appreciates the activities by Queensland Rail (QR) so far to review this issue, and acknowledges that a blanket ban on the use of controlled speed is not necessary. The ATSB notes that QR is undertaking further work to guide the use and conditions around controlled speed and restricted speed, and the ATSB will seek updates on the progress of QR’s additional work to address this issue on a regular basis.
