Recommendation RR20070028


Recommendation details
Output No: RR20070028
Date issued: 14 November 2007
Safety action status:
Background: Why this Recommendation was developed

Output text

Safety Issue

On the day of the commissioning, the engineer and technician had been awake in excess of 14 and 12 hours respectively. The commissioning works required sustained levels of concentration which meant both men were probably suffering from some degree of cognitive fatigue at the end of the day when they inadvertently left the temporary wiring strap in situ. In the case of the signal engineer, any such fatigue would have been compounded by disturbed sleep and his anxiety as a result of a health scare the previous day. Personnel performing safety critical signal work should be fully cognisant of the risks associated with fatigue and any factors which may predispose them to degraded work performance as a result of fatigue. Planning safety critical work should also take into account the risks associated with cognitive fatigue and include measures to effectively mitigate such risks.

Safety Recommendation

The Australian Transport Safety Bureau recommends that WestNet Rail take action to address this safety issue.

Last update 05 April 2012