Reporting and communications were not carried out in accordance with Sydney Trains rules and procedures, so that key employees in the Rail Management Centre received delayed and/or partial information and allowed the train to continue in service.
03 December 2015
Sydney trains advised of the following actions:
Commence an immediate program that insists on the use of approved methods of safety critical communication and continuously monitor the status of this program to effect compliance. This program should consolidate all existing programs to ensure the delivery of an organisation wide standard of communication.
In conjunction with safety action (above), mandate the use of checklists for incident response and sample their use for all defined safety critical responses.
Clarify, train and promote as necessary to all levels of the organisation the correct means of reporting emergency related communication to the Rail Management Centre.
The Australian Transport Safety Bureau is satisfied that the above safety actions if completed and implemented, will address the identified safety issue.
Current issue status:
Safety action pending
At the time of this report release, the safety actions advised by Sydney Trains had not yet been fully implemented. The ATSB is satisfied that the actions proposed by Sydney Trains will, when completed, adequately address this safety issue