Executive summary
On Wednesday, 6 November 1996, at approximately 0648 hours Train 6210, a northbound suburban Electric Multiple Unit service, was stopped by a red signal aspect on the double-track section south of McKays. The Train Control Officer had almost completed the process of issuing a Mis. 59 authority to allow the train to pass the Departure signal at "Stop" and enter the single line section ahead when the locomotive engineer of Train 6210 saw Train 203, the southbound Northerner passenger express, approaching him on the single line section he was about to receive authority to enter. This fortuitous arrival of Train 203 avoided the possible head-on collision which may have resulted if the authority had been issued and acted on with Train 203 in the section.
The cause of the incident was the failure of the Train Control Officer to establish that no trains were occupying the block section for which the Mis. 59 was going to be issued.
Safety issues identified were the Train Control Officer's failure to follow the procedures required before issuing a Mis. 59, the lack of resilience of the procedures to avoid unacceptable consequences arising from such omissions, the Train Control Officer's fitness for duty and the suitability of the procedures for rostering Train Control Officers.