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Deficient handover process

Issue number: RO-2014-021-SI-01
Who it affects: Users the Sydney Trains Network Rules and Procedures
Issue owner: Sydney Trains
Operation affected: Rail: Infrastructure
Background: Investigation Report RO-2014-021
Date: 17 September 2015

Safety issue description

There was a breakdown in the NCO handover process used at Morisset which resulted in ASB being granted to the Protection Officer at Warnervale without the exact location of trains being properly established, signals V8 and V6 being set back to stop and blocking facilities applied in accordance with Network Rule NWT 308.

Proactive Action

Action organisation: Sydney Trains
Action number: RO-2014-021-NSA-022
Date: 17 September 2015
Action status: Released

As a result of this occurrence, Sydney Trains advised that the following safety actions have been implemented:

  • Consider the deployment of Network Operations personnel to oversee the implementation of any required worksite protection controlled by Morisset.
  • Review the current ergonomics of the signal box and station facilities to minimise the potential for distraction of the signaller, from a Human Factors perspective.
  • Consider the possibility of relocating the signalling operations currently carried out at Morisset to a dedicated signal complex.
  • Consider the possibilities of providing a program of maintenance activities to Network Operations to facilitate the deployment of Network Operations personnel to oversee the implementation of any required worksite protection controlled by Morisset.

Concurrently, the ASB rule is also undergoing a complete re-write to improve its readability and application.

ATSB response:

While the Australian Transport Safety Bureau is satisfied that the ‘Coded Absolute Signal Blocking (ASB) process’ will improve the identification of completed steps in the process and the accuracy of information exchanged between parties when granting ASB, these improvements will only be fully realised if the process is fully implemented across the network.  Accordingly therefore, the ATSB issues the following safety recommendation:

Correspondence

Date received: 05 August 2015
Response from: Sydney Trains
Action status: Closed
Response text:

As a result of this occurrence, Sydney Trains advised that the following safety actions have been implemented:

  • Consider the deployment of Network Operations personnel to oversee the implementation of any required worksite protection controlled by Morisset.
  • Review the current ergonomics of the signal box and station facilities to minimise the potential for distraction of the signaller, from a Human Factors perspective.
  • Consider the possibility of relocating the signalling operations currently carried out at Morisset to a dedicated signal complex.
  • Consider the possibilities of providing a program of maintenance activities to Network Operations to facilitate the deployment of Network Operations personnel to oversee the implementation of any required worksite protection controlled by Morisset.
  • Concurrently, the ASB rule is also undergoing a complete re-write to improve its readability and application.
ATSB response:

While the Australian Transport Safety Bureau is satisfied that the ‘Coded Absolute Signal Blocking (ASB) process’ will improve the identification of completed steps in the process and the accuracy of information exchanged between parties when granting ASB, these improvements will only be fully realised if the process is fully implemented across the network. Accordingly therefore, the ATSB issues the following safety recommendation.

Recommendation

Action organisation: Sydney Trains
Action number: RO-2014-021-SR-021
Date: 17 September 2015
Action status: Monitor

The Australian Transport Safety Bureau recommends that Sydney Trains takes further action to expedite the implementation of safeguards and procedural safety enhancements where Absolute Signal Blocking is to be used for worksite protection.

Correspondence

Date received: 01 July 2015
Response from: Sydney Trains
Action status: Closed
Response text:

As a result of this occurrence, Sydney Trains advised that the following safety actions have been implemented:

  • Consider the deployment of Network Operations personnel to oversee the implementation of any required worksite protection controlled by Morisset.
  • Review the current ergonomics of the signal box and station facilities to minimise the potential for distraction of the signaller, from a Human Factors perspective.
  • Consider the possibility of relocating the signalling operations currently carried out at Morisset to a dedicated signal complex.
  • Consider the possibilities of providing a program of maintenance activities to Network Operations to facilitate the deployment of Network Operations personnel to oversee the implementation of any required worksite protection controlled by Morisset.
  • Concurrently, the ASB rule is also undergoing a complete re-write to improve its readability and application.
Date received: 14 September 2015
Response from: Sydney Trains
Action status: Closed
Response text:

Sydney Trains stated: "Sydney Trains agrees with safety recommendation RO-2014-021-SR-021. The safety action being undertaken to address this safety recommendation is the implementation of coded ASB. In order to fully implement coded ASB rule changes and consultation are required. The development of the rules is underway and consultation will follow. At this time it is anticipated that coded ASB will be fully implemented by the end of March 2016".
The ATSB responded: "The Australian Transport Safety Bureau recognises Sydney Trains' continued action on these issues by way of assessing and implementing a Coded ASB worksite protection process. Implementation of coded ASB will also address underlying safety issues RO-2013-018-SI-01, 02, 03 and 04 from the ASB rail investigation RO-2013-018. On the basis therefore, that Sydney Trains remain committed to implementing a new (Coded) ASB rule/procedure, and working on the assurances that this process will result in the lowering of risk associated with worksite protection by ASB, we have re-assessed the status of these issues and will formally close them as ‘Adequately Addressed’. The ATSB would, however, appreciate being provided with appropriate access to the new rulesets once they are implemented."

   
Current issue status: Adequately addressed
Status justification:

Sydney Trains' coded ASB trial has continued while Sydney Trains prepares for full implementation. In order to fully implement coded ASB rule changes and consultation are required. The development of the rules is underway and consultation will follow. At this time it is anticipated that coded ASB will be fully implemented by the end of March 2016. The Australian Transport Safety Bureau recognises Sydney Trains' continued action on this issue by way of assessing and implementing a ‘coded Absolute Signal Blocking process’ and is satisfied that this process, if completed and implemented, will improve how parties confirm the ID & current location of the last train to pass the protecting signals and result in the lowering of risk associated with worksite protection by ASB.On the basis therefore, that Sydney Trains remain committed to implementing a new (Coded) ASB rule/procedure, the ATSB has re-assessed the status of this issue and has formally closed it as ‘Adequately Addressed’.

 
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Last update 22 October 2015