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Production, validation, customer review and distribution of STNs

Issue number: RO-2013-017-SI-03
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Background: Investigation Report RO-2013-017
Date: 19 September 2014

Safety issue description

Sydney Trains validation processes were not effective in detecting errors in Special Train Notice (STN) 1004 prior to the Local Possession Authority (LPA) implementation.

Proactive Action

Action organisation: Sydney Trains
Date: 19 September 2014
Action status: Closed

Sydney Trains acknowledges that the inaccuracy of the Special Train Notice (STN) and relevant rules and procedures not being followed during implementation of the LPA were contributing factors to this incident.

Sydney Trains has implemented a number of changes to their STN production and validation processes and incorporated new tools and systems to improve the integrity of the validation process and make it easier to independently assess possession information.

ATSB response:

The Australian Transport Safety Bureau is satisfied that the action taken by Sydney Trains addresses this safety issue.

Correspondence

Date received: 11 July 2015
Response from: Sydney Trains
Action status: Closed
Response text:

Sydney Trains drew our attention to page 23 of the draft report. At this point the draft report acknowledged that the Tran Planning Unit (responsible for the development and publication of STNs) had implemented a number of process changes based on their internal investigation of this incident; these changes were then listed and the report noted that the Train Planning Unit had ‘….implemented a number of changes to strengthen their production and validation processes.”

Since that initial information was supplied to the ATSB a number of other changes have been made to further strengthen the production and validation processes. These were:

  • The revised validation process now requires the Specifications & Pre Production Officer (Proforma STN / Track Closure owner) and the Train Planner (Train Working Alteration STN owner) and their immediate team leaders to attend a designated validation room 2.5 weeks from the publishing deadline. The validation room has been fitted with the essential validation tools and associated systems to ensure planners collaboratively validate all documents and data intended for publishing to achieve absolute alignment.
  • Track Possession maps now clearly outline the Track Possession boundaries to avoid any overlapping issues when cross checking track closure files. Each map includes the following;
  • Track identification number
  • All structures and identifiers
  • A clear boundary marked on the map to identify any staging variances
  • Further diagrams, e.g. Signal plans or Drivers Route Knowledge Diagrams if signals are used for boundaries
  • Different colours utilised for separate Track Possessions clearly outlining the different boundaries
  • Overlapping track possession maps are to include all dates and times.
  • Track possession identification numbers to be provided on the Proforma STN next to each track possession heading where multiple track possession numbers occur. Clear separation of all related possession information will ensure greater validation integrity and an easier independent assessment of information.
Date received: 11 July 2014
Response from: Sydney trains
Action status: Closed
Response text:

Sydney Trains drew our attention to page 23 of the draft report. At this point the draft report acknowledged that the Tran Planning Unit (responsible for the development and publication of STNs) had implemented a number of process changes based on their internal investigation of this incident; these changes were then listed and the report noted that the Train Planning Unit had ‘….implemented a number of changes to strengthen their production and validation processes.”

Since that initial information was supplied to the ATSB a number of other changes have been made to further strengthen the production and validation processes. These were:

  • The revised validation process now requires the Specifications & Pre Production Officer (Proforma STN / Track Closure owner) and the Train Planner (Train Working Alteration STN owner) and their immediate team leaders to attend a designated validation room 2.5 weeks from the publishing deadline. The validation room has been fitted with the essential validation tools and associated systems to ensure planners collaboratively validate all documents and data intended for publishing to achieve absolute alignment.
  • Track Possession maps now clearly outline the Track Possession boundaries to avoid any overlapping issues when cross checking track closure files. Each map includes the following;
  • Track identification number
  • All structures and identifiers
  • A clear boundary marked on the map to identify any staging variances
  • Further diagrams, e.g. Signal plans or Drivers Route Knowledge Diagrams if signals are used for boundaries
  • Different colours utilised for separate Track Possessions clearly outlining the different boundaries
  • Overlapping track possession maps are to include all dates and times.
  • Track possession identification numbers to be provided on the Proforma STN next to each track possession heading where multiple track possession numbers occur. Clear separation of all related possession information will ensure greater validation integrity and an easier independent assessment of information.
   
Current issue status: Adequately addressed
Status justification:

The Australian Transport Safety Bureau is satisfied that the action taken by Sydney Trains adequately addresses the safety issue.

 
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Last update 22 October 2015