A train driver accidentally ran a stop signal during the busy morning rush, triggering a close call and uncovering a major weakness in Queensland Rail’s safety system.

The Australian Transport Safety Bureau (ATSB) has now released its final report into the incident, which happened on May 24, 2023 between Brisbane’s Fortitude Valley and Bowen Hills stations.

The suburban passenger train passed a stop signal and only came to a halt 64 metres beyond that point.

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Critically, no alarm was triggered, and no alert was sent to Queensland Rail’s network controller, the report showed.

The control room had no idea it happened.

The only way staff found out that a signal passed at danger (SPAD) had occurred was when the driver radioed it in, according to the report.

ATSB Chief Commissioner Angus Mitchell said the warning system in the train did sound an alert, but the driver probably missed the red light because those alerts happen often, all sound the same and, in this case, the driver was briefly unwell.

The driver suffered a sudden sneezing fit as the train approached the red signal and later tested positive for COVID-19.

Although they acknowledged the automatic warning system (AWS) alert, but they did not actually see or register the red light until the train had already passed it.

The driver slammed the emergency brake. The train stopped safely.

Fortunately, another red signal up ahead stopped the train from getting any closer to another train that was only 300 metres away, waiting to pull into Bowen Hills station.

However, the ATSB’s investigation revealed this wasn’t a one-off fluke, but the result of systemic limitations.

Queensland Rail’s signalling set-up does not automatically notify controllers when a train runs a red light, the report explained.

Instead, it relies entirely on the driver noticing their mistake and calling it in.

But as the ATSB points out, that safeguard breaks down completely if the driver doesn’t realise they’ve made an error.

“In most train-to-train collision scenarios, the accident is preceded by at least one train travelling through a stop signal,” Mitchell said.

“Eliminating these SPAD events is therefore a key focus ... towards reducing the risk of accidents.”

The report also found Queensland Rail had not accounted for this risk in its internal safety protocols.

Mitchell said the state rail service hadn’t considered the risk of a SPAD alarm not reaching control or the driver not noticing it.

In response, Queensland Rail said safety remains its highest priority.

“Queensland Rail’s number one priority is the safety of its employees, customers and the community,” said Neil Backer, Head of SEQ.

The rail operator acknowledged the ATSB report and reassured customers preventing SPAD incidents remains a key part of its safety efforts.

Backer said the train company has now several SPAD prevention measures in place, including a dedicated taskforce, new technologies like the rollout of the European Train Control System, and driver education programs.

The operator is also making further changes on the ground, including turning up the volume of alerts, upgrading signal lights to brighter LEDs for better visibility, adding more warning signs, and improving how it manages SPAD risk.

Backer said those steps are working.

“Queensland Rail’s SPAD rate has continued to trend downwards for the past several months,” he said.

Despite the improvements, the ATSB has recommended Queensland Rail re-evaluate risks from undetected SPADs and consider additional safeguards.

“These types of limitations should be eliminated where possible,” Mitchell said.

For now, Queensland Rail continues to rely on its existing warning systems while it works on rolling out the European Train Control System (ETCS), which experts say offers a smarter safety solution able to intervene when humans make mistakes.