Signal Passed At Danger - SPAD

[ozbob]

Why are SPADS quoted / graphed as 'per million kilometers'?
Do we refer to cars running red lights per million kilometres?

I guess without a second metric you wouldn't have a graph. 

Why not show the actual number under the graph?

Given the record on how statistics are reported, it's hard to have any confidence in the data.

Reporting the number of SPADs per million train km is pretty much standard for the rail industry as I understand it FF.

It allows a comparison between systems to account for varying networks etc.  Perhaps someone will know a bit more ...

[achiruel]

Absolute SPADs aren't really a good measure. I'm not sure SPADs per million km is either. SPADs as a percentage of signals passed would be better, but I suspect very difficult to count.

Regarding motor vehicles, not sure about red lights disobeyed, but fatalities are often reported as per million vehicle km (in academic/research literature at least, not so much in Government press releases).

[HappyTrainGuy]

It's just how it's reported as it's a better analytical method.

[ozbob]

https://twitter.com/railbotforum/status/1072038467624792066

[ozbob]

https://twitter.com/railbotforum/status/1083262902281203714

[ozbob]

https://twitter.com/railbotforum/status/1093960917543313408

[ozbob]

https://twitter.com/railbotforum/status/1104466606392930305

[ozbob]

https://www.facebook.com/QueenslandRail/posts/2460409710644041

The train at Park Rd that evacuated customers to the track. I read on 4BC it passed a red signal really close to another train. True or not?

Queensland Rail Hi Dale, yes we can confirm that a train passed a red signal at Park Road station earlier today. Please be assured that every incident like this on our network is taken very seriously and is thoroughly investigated to identify contributing factors and make recommendations to prevent recurrence.

https://www.atsb.gov.au/publications/investigation_reports/2019/rair/ro-2019-009/

Signal passed at danger (SPAD) incident at Park Road Station in Brisbane, Queensland, on 25 March 2019

The ATSB is investigating a signal passed at danger (SPAD) incident at Park Road Station in Brisbane, Queensland, on 25 March 2019.

Queensland Rail (QR) suburban passenger train DW17 (Cannon Hill to Northgate), running on the Down Southern Suburban line, performed a normal station stop at Park Road. After passengers had boarded and the doors had been closed, the guard provided the 'rightaway' signal to the driver.

At this time, signal DP29, located at the end of Park Road platform, displayed a red aspect. Train DW17 departed at 1216, passing signal DP29 at danger and exceeding its authority.

Signal DP29 was displaying a red aspect because another suburban passenger train 1E65 (Beenleigh to Ferny Grove) was running in the same direction through Park Road Station, on the parallel Middle Road.

The Down Southern Suburban line and the Middle Road converge at the 643A/B points, located approximately 230 m from the station, just before the rail bridge over Annerley Road. The points had been set to allow train 1E65 to move from the Middle Road to the Down Southern Suburban line, and run ahead of train DW17.

On advice from the network control officer, trains DW17 and 1E65 stopped. By this time, train DW17 had run through the 643A/B points. 

As part of the investigation, the ATSB will interview the crews of both trains, and review video footage, train event recorder data and information from QR's Rail Management Centre.

A final report will be released at the end of the investigation.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

[ozbob]

Signal ME45 passed at danger resulting in a near-miss between suburban passenger trains TP43 and TR50 at Bowen Hills, Queensland on 10 January 2018

Interim report > https://www.atsb.gov.au/publications/investigation_reports/2018/rair/ro-2018-002/

[timh]

https://www.facebook.com/QueenslandRail/posts/2460409710644041

The train at Park Rd that evacuated customers to the track. I read on 4BC it passed a red signal really close to another train. True or not?

Queensland Rail Hi Dale, yes we can confirm that a train passed a red signal at Park Road station earlier today. Please be assured that every incident like this on our network is taken very seriously and is thoroughly investigated to identify contributing factors and make recommendations to prevent recurrence.

https://www.atsb.gov.au/publications/investigation_reports/2019/rair/ro-2019-009/

Signal passed at danger (SPAD) incident at Park Road Station in Brisbane, Queensland, on 25 March 2019

The ATSB is investigating a signal passed at danger (SPAD) incident at Park Road Station in Brisbane, Queensland, on 25 March 2019.

Queensland Rail (QR) suburban passenger train DW17 (Cannon Hill to Northgate), running on the Down Southern Suburban line, performed a normal station stop at Park Road. After passengers had boarded and the doors had been closed, the guard provided the 'rightaway' signal to the driver.

At this time, signal DP29, located at the end of Park Road platform, displayed a red aspect. Train DW17 departed at 1216, passing signal DP29 at danger and exceeding its authority.

Signal DP29 was displaying a red aspect because another suburban passenger train 1E65 (Beenleigh to Ferny Grove) was running in the same direction through Park Road Station, on the parallel Middle Road.

The Down Southern Suburban line and the Middle Road converge at the 643A/B points, located approximately 230 m from the station, just before the rail bridge over Annerley Road. The points had been set to allow train 1E65 to move from the Middle Road to the Down Southern Suburban line, and run ahead of train DW17.

On advice from the network control officer, trains DW17 and 1E65 stopped. By this time, train DW17 had run through the 643A/B points. 

As part of the investigation, the ATSB will interview the crews of both trains, and review video footage, train event recorder data and information from QR's Rail Management Centre.

A final report will be released at the end of the investigation.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

I hope to God it doesn't end up being that this was a newly trained driver at fault, especially since railfail we've been reading all the stuff about rushed training, cheating on exams, etc. S#!t would really hit the fan for QR if a near miss like this was caused by one of said poorly trained drivers...

[HappyTrainGuy]

Lots of spads in that area. Some of the most serious. Ironically the courier mail missed most of them in their 'exclusive' foi investigation haha.

[ozbob]

Signal Passed At Danger (SPAD)https://t.co/NNq4eGBp1Z#qldpol pic.twitter.com/JDaLE9mmtb

— RAIL_BoT_Forum (@railbotforum) April 10, 2019

[achiruel]

Does anyone have any info on other operator's SPAD stats, e.g. TransPerth? Would be good for comparison.

[ozbob]

https://twitter.com/railbotforum/status/1126693498067902465

[ozbob]

https://twitter.com/railbotforum/status/1137884371061338112

[ozbob]

https://twitter.com/railbotforum/status/1148970864911630338

[ozbob]

Signal Passed At Danger (SPAD) @QueenslandRail - updated for June 2019https://t.co/NNq4eGBp1Z#qldpol pic.twitter.com/IxaMNFzg3v

— RAIL_BoT_Forum (@railbotforum) August 9, 2019

[ozbob]

Details of the issue at Elimbah this morning have been by posted by @QueenslandRail on Facebook https://t.co/UDevFe3SZ3#qldpol pic.twitter.com/69UG9nWoUQ

— RAIL_BoT_Forum (@railbotforum) August 27, 2019

[red dragin]

That's a carton! (And a training session, counselling etc)

Good on QR for being upfront on that one.

[achiruel]

Interestingly, it seems the post has been deleted from Facebook. Good thing ozbob got a screenie.

[ozbob]

Interestingly, it seems the post has been deleted from Facebook. Good thing ozbob got a screenie.

I did note some comments on the original QR FB post from apparent insiders upset that QR had posted the photograph and gave an explanation.

I guess they won out.  I thought it was good that there was an explanation.  Everyone had moved on, stuff happens.  Guess the non-transparent tell them nothing camp prevailed.  At least I got it.

Cryptic nonsense no doubt will continue.  They really should have a read of Sydney Trains and Scot Rail twitter feeds for example.  They regularly post photographs of the problems with good explanations.  Some in QR realise that being upfront and accurate is better than obfuscation and non-transparency.  Transparency actually builds confidence.  Others are still trapped in the past failed paradigm.

[ozbob]

https://twitter.com/railbotforum/status/1171321458980581377

[ozbob]

https://twitter.com/railbotforum/status/1182375139817582593

[ozbob]

Queensland Parliament Questions On Notice

https://www.parliament.qld.gov.au/documents/tableOffice/questionsAnswers/2019/1390-2019.pdf

QUESTION ON NOTICE
ASKED

Tuesday, 17 September 2019

Answer Due: Thursday, 17 October 2019

1390 MR S MINNIKIN ASKED MINISTER FOR TRANSPORT AND MAIN ROADS (HON M BAILEY)

With reference to commuter safety—
Will the Minister outline the number of Signals Passed at Danger (SPAD) recorded by Queensland Rail,
(reported separately by month for 2018 to 2019) and the five most frequent services that have recorded
SPADs since 1 January 2018 (reported separately by service)?

============

Answer is due today ...

[ozbob]

Answer has been tabled...

==========

https://www.parliament.qld.gov.au/documents/tableOffice/questionsAnswers/2019/1390-2019.pdf

Question on Notice
No. 1390
Asked on Tuesday 17 September 2019

MR S MINNIKIN ASKED MINISTER FOR TRANSPORT AND MAIN ROADS (HON M BAILEY)
QUESTION:

With reference to commuter safety—
Will the Minister outline the number of Signals Passed at Danger (SPAD) recorded by
Queensland Rail, (reported separately by month for 2018 to 2019) and the five most frequent
services that have recorded SPADs since 1 January 2018 (reported separately by service)?

ANSWER:

I thank the Member for Chatsworth for the question.

The safety of Queensland Rail's network, employees and customers is the organisation's highest
priority. While Signal Passed at Danger (SPAD) incidents are an industry-wide issue faced by rail
operators all over the world, Queensland Rail maintains a dedicated focus on managing the rate
of SPADs on its network.

In 2018–19, Queensland Rail recorded its lowest SPAD rate in more than two decades, with
1.61 SPADs per million train kilometres travelled, which was below the target of 1.78.
In January 2019, Queensland Rail recorded its best-ever SPAD rate of 1.44, which represented
an 86 per cent improvement in the number of SPADs compared with January 2018.
Since February 2018, Queensland Rail has seen steady improvement in the rate of SPADs on its
network, following the implementation of a dedicated SPAD Prevention Taskforce in
October 2017, including a range of additional control measures. This taskforce has 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 levels of engagement with staff.

Since February 2018, the taskforce has implemented new toolbox talks for staff, increased
one-on-one engagement with train drivers to improve SPAD awareness, and made physical
changes to signalling infrastructure at a number of locations including Normanby, Northgate and
Bowen Hills. Queensland Rail also appointed an organisational psychologist specialising in
human performance in safety critical settings to work directly with its train drivers and help guide
the work of the taskforce.

The taskforce has also commenced analysing event recorder data from SPAD occurrences and
incident-free running, which has assisted with identifying train-handling behaviour that has a
known relationship to SPAD causation and is being used to further improve driver training and
awareness.

Queensland Rail has advised the following number of reported SPADs, separately by month for
2018 to 2019.



There is no significant correlation between SPAD occurrences and individual train services. In
the period from 1 January 2018 and 17 September 2019, there was only one service which
recorded more than one SPAD, which was service 1E41.

However, the two SPAD incidents experienced by this service occurred at different locations on
the network (Kingston on 10 July and Bowen Hills on 8 August 2019) and involved different
drivers.

[ozbob]

^

Plot of the data in QON #1390

[ozbob]

https://twitter.com/railbotforum/status/1184916811663327232

[ozbob]

Infrastructure --> SPAD Prevention Taskforce pays off for Queensland Rail

January 2019 marks the lowest Signal Passed at Danger (SPAD) rate in Queensland Rail's history, after the organisation implemented a range of SPAD prevention controls and initiatives, including a dedicated taskforce, in 2017.

An SPAD occurs when a train passes a red stop signal and occupies a section of track without authority to do so. SPAD incidents can occur for varying reasons, and are industry-wide and faced by rail operators all over the world.

Drivers who are involved in SPAD incidents are removed from duty, undergo alcohol and drug testing, debrief and safety investigation, and must pass a competency assessment and undergo on-track monitoring to confirm their skills prior to returning to driving duties.

Queensland Rail CEO, Nick Easy, said safety was the organisation's top priority.

"We're extremely pleased to have seen our SPAD rate decrease steadily since February 2018, to the point where we recorded our organisation's best-ever SPAD rate last month of 1.44 SPADs per million train kilometres travelled," Mr Easy said.

"This is a rate improvement of 43 per cent compared with January 2018, when we recorded a peak SPAD rate of 2.53."

Since its establishment in October 2017, the SPAD Prevention Taskforce has 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 levels of engagement with staff.

In October 2018, the organisation also appointed an Organisational Psychologist specialising in human performance in safety critical settings to work directly with its train drivers and to help guide the work of the Taskforce.

Since then, taskforce has implemented new toolbox talks for staff, increased one-on-one engagement with train drivers to improve SPAD awareness, and physical changes to signalling infrastructure at a number of locations including Normanby and Northgate.

Mr Easy said every SPAD on the Queensland Rail network was taken very seriously and investigated thoroughly to identify all contributing factors and to make any recommendations to prevent recurrence.

This achievement comes as Queensland Rail assists the Australian Transport Safety Bureau (ATSB) with its investigation into a SPAD incident which occurred on 10 January 2018 at Bowen Hills, for which the ATSB has released its interim report.

"We welcome the release of the interim report and will continue to work with and assist the Bureau as it continues its more detailed investigation," Mr Easy said.

Queensland Rail has identified and implemented engineering solutions for the signal involved in this incident at Bowen Hills (ME45) to improve visibility at the site for drivers, provide advanced warning of the signal, and reduce the likelihood of further SPADs at this location.

These changes involved upgrading the LED aspects of the signal to reduce the risk of drivers viewing signals incorrectly, relocating the stopping marker at Bowen Hills station to provide drivers with a better line of sight, and from 24 February 2019 the signal is now preceded by two warning signals instead of one.

Queensland Rail has also commenced reviewing and identifying improvements to its maintenance of competency (MoC) assessment, undertaken by existing train drivers every 18 months or following a SPAD incident, to ensure the MoC process is efficient and in line with industry best practice.

From April 2019, Queensland Rail will transition to a revised theory assessment as part of the MoC process, with updated questions and content which will be administered through a classroom-based group setting, rather than on an individual basis wherever practical.

Mr Easy said this was in line with contemporary adult learning practices and the process adopted by many other rail operators in undertaking MoC assessments.

"The MoC process is only one component of Queensland Rail's comprehensive assurance process for existing drivers," he said.

Other components will include regular analysis conducted of train event recorders, which function like an airplane 'black box', to identify and manage driver behaviours, in addition to on-track assessments by driver supervisors.

"The SPAD Taskforce has already delivered significant improvements in terms of reducing the rate of SPADs on the network and this strong focus will continue," Mr Easy said.

There have been no Citytrain collisions as a result of a SPAD on the South-East Queensland network since 1996.

[ozbob]

[ozbob]

Sent to all outlets:

18th October 2020

Signal Passed At Danger (SPAD) - Queensland Rail continues to reduce SPAD rate

Greetings,

" A signal passed at danger (SPAD) is an occurrence where a train passes a signal displaying a stop indication without the authority to do so.
Only a small percentage of SPADs result in a serious accident but they provide warnings about failures or deficiencies in safety risk controls, including those associated with human factors."
( https://www.onrsr.com.au/safety-improvement/signals-passed-at-danger )

Queensland Parliament Question On Notice #1390 has confirmed the reduction in SPAD incidence on Queensland Rail.
https://www.parliament.qld.gov.au/documents/tableOffice/questionsAnswers/2019/1390-2019.pdf

" In 2018–19, Queensland Rail recorded its lowest SPAD rate in more than two decades, with 1.61 SPADs per million train kilometres travelled, which was below the target of 1.78. In January 2019, Queensland Rail recorded its best-ever SPAD rate of 1.44, which represented an 86 per cent improvement in the number of SPADs compared with January 2018. Since February 2018, Queensland Rail has seen steady improvement in the rate of SPADs on its network, following the implementation of a dedicated SPAD Prevention Taskforce in October 2017, including a range of additional control measures. This taskforce has 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 levels of engagement with staff. ... "

A plot of the SPAD data in the Answer to the Question On Notice



Well done all at Queensland Rail.

Robert Dow
Administration
admin@backontrack.org
RAIL Back On Track https://backontrack.org

Reference:

Infrastructure --> SPAD Prevention Taskforce pays off for Queensland Rail
https://infrastructuremagazine.com.au/2019/03/04/spad-prevention-taskforce-pays-off-for-queensland-rail/

[ozbob]

https://twitter.com/railbotforum/status/1192647819607203840

[ozbob]

https://twitter.com/railbotforum/status/1204222963915968512

[ozbob]

https://twitter.com/railbotforum/status/1227122904451579905

[ozbob]

https://twitter.com/railbotforum/status/1237506052339335168

[ozbob]

https://twitter.com/railbotforum/status/1250437892830199811

[ozbob]

https://twitter.com/railbotforum/status/1259718148497895424

[ozbob]

https://twitter.com/railbotforum/status/1271234111898705920

[ozbob]

https://twitter.com/railbotforum/status/1281628600542740481

[ozbob]

https://twitter.com/railbotforum/status/1292896173011767296

[ozbob]

https://twitter.com/railbotforum/status/1304238693566181376