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Auditing not effective

Issue number: RO-2013-018-SI-05
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Background: Investigation Report RO-2013-018
Date: 02 March 2015

Safety issue description

The Sydney Trains regime for auditing worksite protection arrangements was not effective in identifying emerging trends or safety critical issues when using Absolute Signal Blocking (ASB).

Recommendation

Action organisation: Sydney Trains
Action number: RO-2013-018-SR-085
Date: 02 March 2015
Action status: Released

The Australian Transport Safety Bureau recommends that Sydney Trains undertake further work to ensure that future auditing of worksite protection arrangements is effective in identifying issues with the implementation and use of Absolute Signal Blocking as a method of safeworking.

Correspondence

Date received: 02 April 2015
Response from: Sydney Trains
Response text:

Sydney Trains response to Safety REC RO-2013-018-SR-085 re. Coded ASB trial and auditing of worksites. Sydney Trains advises: "...the Coded ASB trial for the protection of maintenance activities has been successfully concluded and it is intended to roll out those changes to the ASB process across our network. This will be achieved by developing and issuing amendments to the current ASB rule and procedure......It is anticipated that full implementation of the coded ASB should be complete in mid-2016".
Auditing: Sydney Trains states: "Sydney Trains agrees with the safety issue and our safety action to address the issue is the development of a programme of random audits that will assess the effectiveness and compliance to Sydney Trains' Network Rules and Procedures work on track rules and procedures with a focus on NWT 308 ASB Working. These audits will commence during April 2015. The scope of the audits will apply to worksites performing work inside the rail corridor that are under the control of Sydney Trains. Unannounced sites will be selected randomly and audits will consider compliance and risk; identified from statistical, incident and investigation findings." No end date is provided.

Date received: 01 May 2015
Response from: Sydney Trains
Response text:

The ATSB is proceeding to monitor all the proposed safety actions and Safety Recommendation RO-2013-018-SR-085 and would appreciate periodical updates as to the progress with their implementation. We would appreciate an update on the progress in implementation of all the planned actions as at the end of August 2015 by 10 September 2015. Includes a response by Sydney Trains, followed by an explanation by A/GM Surface Safety as to intent of ATSB monitoring.

Date received: 08 September 2015
Response from: Sydney Trains
Action status: Closed
Response text:

Sydney Trains stated: "the issue was closed out in the St James Issue and Action Management application (SJAMS) on 8 May 2015 on the basis that a Preliminary Worksite Protection Audit schedule for 2015 was developed and the first audit was carried out on 8/9 April 2015 with a final report provided to stakeholders. Further audits have been carried on a monthly basis per the Worksite Protection Audit schedule with the latest having been completed in August 2014."
The ATSB sought extra detail from Sydney Trains, specifically to provide a summary on the parameters of the audit schedule, particularly specific issues associated with the implementation and use of ASB and any further action proposed as a result.

Date received: 23 September 2015
Response from: Sydney Trains
Action status: Closed
Response text:

Sydney Trains provided extra detail on the worksite protection auditing both undertaken and proposed to address the recommendation RO-2013-018-SR-085. Three documents were attached in support of information in their response. In their response, Sydney Trains stated: "Sydney Trains undertakes compliance audits of worksites within the rail corridor, specifically targeting the application of Absolute Signal Blocking (ASB) work on track method (where possible). As the audits are unannounced and ASB does not require significant pre-notice the audits will not always find ASB worksites. The audits are known as Application of Worksite Protection Audits and are conducted through onsite interviews, verification of worksite protection plans / pre-work briefs against Sydney Trains Network Rules and Procedures and other requirements under the Sydney Trains Rail Corridor Safety Program. Sydney Trains’ Network Rules and Procedures, specifically the Work on Track Rules, prescribe the requirements for undertaking activities in the rail corridor and mandate the ways to plan for and achieve the separation of rail traffic from people working on or about track.

The audits are undertaken two days per month and include randomly selected worksites, within the danger zone, on the Sydney Trains network. All worksites which are encountered by the audit team within the rail corridor are audited to assess the level of conformance to Sydney Trains Network Rules and procedures. A detailed audit checklist specifically aligned to the application of the criteria for ASB is utilised by the audit team in the field. The requirements for Coded ASB, currently under trial within Sydney Trains, will be incorporated into the audit checklist tool once the process is formally implemented into the Network Rules and Procedures.

The audit schedule is determined and approved by Group Manager Quality Systems and the audit events are maintained through the Sydney Trains integrated audit management SharePoint site. The audit SharePoint site provides an overview of the audit program for Sydney Trains and provides complete visibility of audit programs for Sydney Trains. It provides detailed information about scope, type, location, auditor, etc. Audit schedule adherence is managed and governed by executive management through the organisational Visual Management Cell (VMC) process and SEQR Audit Working Group meetings.

These audits commenced in April 2015. To date, a total of five Application of Worksite Protection Audits have been completed. The audit team encountered a total of 29 worksites which were undertaking various types of work within the rail corridor during this period. Five of the worksites were applying Absolute Signal Blocking (ASB) work on track method. There were six findings relating to ASB sites. With the exception of the non-conformance identified, all findings were actioned and fully closed out at the time of the audit by mentoring / coaching of the staff by the audit team’s Rail Corridor Safety Program Mentor."

ATSB response:

The Australian Transport Safety Bureau recognises Sydney Trains' continued action on the associated safety issue by way of implementing a Preliminary Worksite Protection Audit schedule. The Australian Transport Safety Bureau is satisfied that this action taken by Sydney Trains adequately addresses this safety issue.

   
Current issue status: Adequately addressed
Status justification:

Sydney Trains undertook targeted assurance activity within an ongoing Worksite Protection Audit schedule, focusing on ASB implementation, identifying areas of improvement and providing feedback to staff. With the exception of one non-conformance identified, all findings were actioned and fully closed out at the time of the audit by mentoring / coaching of the staff. The non-conformance was the subject of a recommendation to undertake further coaching intervention with the Protection Officer and work team members of the worksite.The Australian Transport Safety Bureau recognises Sydney Trains' continued action on the associated safety issue. The Australian Transport Safety Bureau has reassessed the level of risk associated with this safety issue, based upon Sydney Trains' advice of action by way of a Worksite Protection Audit. The Australian Transport Safety Bureau is satisifed that this action taken by Sydney Trains has adequately addressed the safety issue.

 
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Last update 22 October 2015