Fatigue, High Workload Cited in ATSB Investigative Report

A network control officer intervened to prevent a collision when an operator drove an empty Sydney Trains passenger train in the wrong direction in March 2015.

The Australian Transport Safety Bureau has completed its investigation of a March 12, 2015, early-morning incident when a Sydney Trains passenger train traveling in the wrong direction came close to colliding with a Pacific National freight train. The report on investigation RO-2015-005 shows that the Sydney Trains operator drove 761 meters, nearly half a mile, in the wrong direction at about 5:13 a.m. before braking after a network control officer contacted him and told him to stop. Only the driver and a guard were on board the passenger train at the time; the freight train was about four kilometers away and traveling toward the passenger train on the same line. The control officer also called the driver of the freight train and told him to stop, so no injuries or damage occurred.

The board found that several factors contributed to the driver’s losing awareness of the way the train was facing. It was likely the driver was:

  • confused about the direction due to changing ends seven times
  • distracted from the main task of driving because he had spent more than three hours at a station performing other tasks before he started driving
  • at risk of making an error due to his high workload
  • feeling under pressure to move the train
  • impaired by fatigue due to being awake for more than 21 hours and in the low range of the circadian sleep cycle

The board concluded Sydney Trains' fatigue management processes were ineffective in identifying the driver's impairment, and that the guard took no action to stop the train although the guard was aware it was traveling in the wrong direction. However, the guard twice had told the driver that "he was in the wrong end for the instructed direction of travel," according to the board.

Sydney Trains has conducted an internal safety investigation and is implementing several safety actions in response to that internal report, according to the report.

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