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Documented instructions

Issue number: RO-2015-002-SI-01
Who it affects: All owners, operators and maintainers of railway infrastructure.
Issue owner: Public Transport Authority of Western Australia
Operation affected: Rail: Infrastructure
Background: Investigation Report RO-2015-002
Date: 07 September 2015

Safety issue description

The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment.

Proactive Action

Action organisation: Public Transport Authority of Western Australia (PTA)
Action number: RO-2015-002-NSA-01
Date: 10 March 2016
Action status: Closed

The PTA advised that maintenance workers are trained and competent to determine the appropriate level of worksite protection. Furthermore, the PTA stated that ‘by not mandating particular rules to particular tasks, the PTA empowers workers to best determine which level of worksite protection best meets the needs of the task/s being performed’.

Notwithstanding this, the PTA advised of the following safety action:

Following the incident at Guildford, the PTA issued Safety Alert PTA01/15 stating that all employees required to work within, or likely to enter, the danger zone must be protected from rail traffic. The Safety Alert also reinforced the requirements of lookout protection.

The PTA also advised that they intend to withdraw the existing Network Rule 191 and replace it with Rule 3013 on 1 August 2015; this being the initial phase in aligning PTA with the Australian Network Rules and Procedures (ANRP). This will provide qualified employees with the following addition protection:

  •          People performing the role of Lookout have a higher level of training and can only perform that duty;
  •          Sighting distance must be measured and confirmed;
  •          Restricts the type of work being done as only hand tools can be used;
  •          Lookouts must have a break every 60 minutes;
  •          Only two Lookouts are allowed;
  •          Provides instruction for worksites using noisy machinery;
  •          Implements the role of the Protection Officer (Level 1);
  •          Provides detailed placement and actions of the Lookout and the workers; and
  •          The Process must be documented.

The PTA would provide additional training to all track workers in the use of the new Rule 3013 Lookout Working.

In addition to this, the PTA advised that the General Manager Network Infrastructure had instructed maintenance personnel to adhere to PTA rules and procedures, and that activation of the level and pedestrian crossing was not considered a method of worksite protection.

 

ATSB response:

The ATSB acknowledges that the PTA have taken steps to implement an improved version of lookout working (Rule 3013), but notes that the rule in place at the time of the incident (Rule 191) was largely consistent with the requirements of the new rule. That is, workers are warned of approaching trains, required to stop work, move to a place of safety, and allow the train to pass before returning to work.

While trained workers should be competent at determining the required level of worksite protection, the ATSB found that, when conducting maintenance on automatic pedestrian crossing equipment, some workers implemented the requirements of lookout working while others did not. That is, some workers would carry out the maintenance task (within the danger zone) while rail traffic was passing; an approach adopted by the maintenance team at Meadow Street level crossing on 10 February 2015.

The PTA’s safety alert states that workers must be protected from rail traffic and implies that lookout working is considered the minimum level of worksite protection applicable to the task of maintaining automatic pedestrian crossing equipment.

   
Current issue status: Adequately addressed
Status justification:

The ATSB is satisfied that the actions taken by the PTA significantly reduces the safety risk, and when combined with completion of the additional training should fully address this safety issue.

 
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Last update 10 March 2016