Page:ATSB RO-2018-004 - Collision of passenger train A42 with buffer stop.pdf/25

 the brakes in order to come to a smooth stop. He said that he was not using his mobile phone, and the phone records confirm that no messages or calls were made or received in the time leading up to the event. There was no one else in the cabin with the driver.

There is no evidence of distraction to the driver and in the absence of any in-cab CCTV footage, the investigation could only rely on the testimony of the driver and the recorded actions on the event recorder. On all occasions, from his initial conversations with the replacement guard, the train guard, and the police, to his formal interviews, the driver’s recollection was consistent: that he did not know what happened to him but experienced some kind of blackout.

The driver’s operation of the train and the performance of the train were analysed for the duration of the journey from Blacktown to Richmond. The driver’s actions were found to be generally in line with the performance standards set down by Sydney Trains. The only area of concern was the previously described over-speeding events where the driver exceeded the maximum speed for the section of track on two occasions. These infractions were for a few kilometres per hour above the limit for a few seconds. The driver’s train driving history was examined for any previous similar incidents since commencing driving trains. Since starting as a driver in November 2007, there were eight recorded incidents where the driver has either failed to stop at a station, overshot the platform or passed a signal at stop. A variety of reasons are recorded for these lapses: distracted, misjudged, lost situational awareness and lost concentration. On each occasion, Sydney Trains has counselled or coached the driver to be more vigilant and to maintain situational awareness. Sydney Trains was unable to say if this was an above-or below-average error rate for drivers. This investigation made no determination on the driver’s recorded error rate but includes it in the report for completeness.

Rail operators use a range of measures to reduce the risk of driver error. This section will focus on the technology-based devices that may have prevented or mitigated the effects of this collision.

These devices include:
 * a vigilance control system
 * an operator enable system
 * a train stop and trip gear system
 * an automatic train protection system.

The first three measures were already in use on the Sydney Trains network and on A42 at the time of the collision at Richmond. The last measure, automatic train protection, was not in use on the network at the time of the collision.

ASA have published a standard for train (driver) safety systems. This standard applies to Sydney Trains and rolling stock operating on the Sydney metropolitan rail network. The standard covers onboard safety systems that protect train safety in the event of a failure in the manual functions of train operation, such as the driver becoming incapacitated approaching a buffer stop. Another ASA specification for passenger rolling stock driver safety systems provides greater detail for the application of these systems.