Rail safety issues and actions
Recommendation issued to: TransAdelaide
|Date issued:||20 December 2007|
|Safety action status:|
|Background:||Why this Recommendation was developed|
TransAdelaide's SPAD investigation process was unlikely to have provided a clear understanding of factors that may have contributed to past SPADs or a sound basis for identification of safety actions to prevent similar occurrences. A recommended action in TransAdelaide's SPAD risk management plan was the establishment of a SPAD investigation group to investigate individual SPADs, compile data, conduct analysis, determine trends, make recommendations, report and oversee implementation. It was not evident that this recommendation had been fully implemented at the time of the incident.
The Australian Transport Safety Bureau recommends that TransAdelaide undertake further work to address this safety issue.