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Mode Rail
Reference No. RR201300009
Date reported 18 June 2013
Concern title Non-reporting of Category A (Cat A) rail incidents by operator
Concern summary

The concern related to how the operator was categorising incidents and hence not reporting Cat A incidents to the regulator.

Industry / Operation affected Rail: Freight
Concern subject type Rail: Network operations

Reporter's concern

The reporter expressed a safety concern regarding the reporting of Cat A occurrences by the operator to the Western Australian Office of Rail Safety (ORS).

The reporter stated that there is a lack of understanding within the operator of the regulatory reporting requirements and consequently, Cat A occurrence were not being reported to the ORS. The reporter stated that as no-one person has responsibility to decide if an incident is a Cat A or a Cat B, Train Control presume that it is a Cat B and that the incident does not have to be reported according to procedures.

The reporter also stated that due to commercial pressure to keep trains running, evidence was being lost when a full investigation should have been completed.

Operator's response (Operator 1)

We refer to the above mentioned Repcon Report regarding a concern about our reporting of notifiable occurrences under the Rail Safety Act 2010 (WA) (RS Act).

We confirm that we have in place incident management procedures covering the reporting and investigation of Category A and B notifiable occurrences. These procedures also cover the preservation of evidence at the scene of a serious accident. Rail personnel responsible for assessing and reporting notifiable occurrences have access to and understand these procedures.

Under our internal procedures:

a) a manager has the primary responsibility for assessing whether an incident should be classified as a Category A or Category B notifiable occurrence with reference to the RS Act and Rail Safety Regulations 2011 (WA) (RS Regulations); and

b) the General Manager of our railway operations is primarily responsible for reporting notifiable occurrences as required by the RS Act and the RS Regulations.

We believe that all Category A and B notifiable occurrences have been appropriately assessed and reported consistently with our internal procedures, the RS Act and the RS Regulations.

Regulator's response (Regulator 1)

There is insufficient information to identify what occurrence is being referred to and therefore be able to assess whether it has been categorised correctly or not.

From our experience dealing with the operator their response to the ATSB appears to be correct.

In general our experience is that rail companies try their best to determine the correct category when reporting to the ORS. We currently have no evidence of under-reporting. We also audit operators to check for this.

Staff in rail operating organisations keep changing and new people with the responsibility for reporting need to learn the reporting and categorisation requirements in our law and in our Occurrence Notification - Standard One (ON-S1). This office spends a lot of time trying to educate them to report and categorise correctly. We often talk about whether an occurrence is Cat A or Cat B and try to agree on the 'top event', sometimes from a very garbled description in the initial report. However, even if an occurrence was wrongly classified, our internal review process would pick it up. A discussion with operators then follows to clarify details and events and to make any corrections required. This is something that ATSB could not do and why reporting should be to the regulator.

ATSB comment

The reporter provided the ATSB with feedback about the responses received in relation to this report and REPCON provided both the operator and the regulator with a copy for comment.

The report provided is below:

We have received some follow up information from the reporter in relation to this report and would like share this with you and get a response.

The reporter has advised that they are not disputing the fact that the organisation has a procedure in place; they are reporting that the procedure is fundamentally flawed and poorly briefed to staff. The procedure does not mirror the requirements in the Rail Safety Act and AS4292, and by your own admission, in the response to the REPCON, their procedures only cover the preservation of evidence at the scene of a serious accident. AS4292 and the Rail Safety Act do not only require the preservation of evidence in the case of incidents which meet the definition of a serious incident but for other incidents where a thorough investigation would help prevent serious incidents / accidents.

The reporter is concerned that although employees are reporting things in accordance with the organisation's procedures, serious incidents are not being reported to the ORS as these procedures are flawed. He points to an investigation into a potential head on collision, which was observed on a train control work station with trains on two routes heading towards each other, and both drivers getting proceed aspects. 12 hours after the incident, it was discovered that as the incident had not been classified as a CAT A no evidence had been preserved and there were no procedures in place for staff to preserve and record the incident.

After the subsequent investigation, a lessons learnt workshop was conducted with the Signals & Systems dept. (Train Control did not send a representative), the poignant parts of AS4292 and Rail Safety Act were highlighted and compared to the operator's procedures and it was agreed that there were some major differences. Staff members later requested to be provided with a SMTH (Network Rail UK signals wrong side failure investigation book) equivalent, training and competency systems for dealing with potential and actual incidents from their management. The issue is that it is not just the Signals department that need these procedures within the organization.

Operator response 2

We refer to your subsequent correspondence, in relation to Repcon Brief No. AR201300009 regarding some remaining concerns about our procedures with respect to notifiable occurrences under the Rail Safety Act 2010 (WA) (RS Act) and the Rail Safety Regulations 2011 (RS Regs).

We confirm that our procedures for reporting of notifiable occurrences and preservation of evidence following such incidences are consistent with the requirements of the RS Act and RS Regs. The reporter had expressed concern that no evidence had been preserved in relation to an incident. We understand this to be a reference to an incident on [date]. We confirm that in relation to the Incident there was no accident that occurred, there was no physical evidence of any accident on site that needed to be preserved in the circumstances. However, in relation to any electronic or other data held in our systems recording the incident, these are always retained by the business for operational reasons and to assist in any subsequent investigations or shared key learnings forums.

Relevant personnel (including Operations, Maintenance and Health and Safety personnel) have a requirement to follow incident management procedures (including access to incident reports). The Health and Safety Team and the Rail Safe working Team are familiar with our incident reporting requirements and personnel from these teams are available to provide support and guidance to personnel on site, including following an incident at any time. If the classification of an incident is unclear, it is our practice to promptly report the matter to the Office of Rail Safety (WA) to seek clarification.

We acknowledges that the Incident in question did involve a failure of one of the electronic components of the train control system, however, it confirms that train control personnel at the time had identified the issue and immediately suspended train movements in the relevant section until they had assessed it to be safe to resume operations. It was not assessed to be a Category A or B notifiable occurrence. The Office of Rail Safety (WA) has been advised of the Repcon report and are also aware of our continuous improvement initiatives (including the updating of rail safety documentation).

We aim to learn from all incidents and accidents. The findings from the lessons learnt workshop associated with this incident have been fed into our current improvement work, together with other information used to continuously improve our systems (including findings from investigations of this incident and other incidences, working groups and workshops).

Regulator response 2

It appears likely from the operator's statement you copied that the train control system 'failed safe' and safety was not compromised. It does not appear to be a notifiable occurrence.

If the incident they have identified is the same as the one from your reporter, then we note that it involved an electronic system issue and that data on the incident was recorded and is still preserved, as it should be. There is therefore no loss of evidence as claimed by the reporter and there is no evidence to support claims of a serious incident not being reported, or of any incident not being properly classified.

As previously advised, and based on our experience dealing with the operator, it appears that their responses to the ATSB appear to correctly set out their robust approach to incident management. They always demonstrate a high commitment to continuous learning and safety improvement.

ATSB comment 2

The ATSB would like to note that we regularly contact operators to obtain additional information and/or to clarify reports.

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Last update 24 March 2014