Mode Rail
Reference No. RR201400011
Date reported 25 August 2014
Concern title The excessive time taken to investigate minor incidents is resulting in rail workers not reporting safety incidents
Concern summary

The concern related to the time it takes the operator to investigate minor incidents. This results in all workers who are involved in an incident being stood down. This has an unintended result of making workers hesitant to report safety incidents.

Industry / Operation affected Rail: Infrastructure
Concern subject type Rail: Track infrastructure

Reporter's concern

The reporter expressed a safety concern regarding the length of time it takes to investigate minor incidents involving track workers.
The reporter advised that track workers can be stood down indefinitely pending an investigation into an incident. This often results in workers, including those who may proactively report an observed safety incident and later are cleared of any involvement, being stood down for extended periods of time.

Internal investigations into safety incidents are perceived to take an extended period of time (often due to the investigators workload) before they are finalised. An unintentional consequence is that track workers are being discouraged from proactively reporting safety incidents, as their action [of reporting the matter] could be penalised regardless of their involvement. 

Operator's response (Operator 1)

The report is general in nature but it does make specific reference to ‘a safety concern regarding the length of time it takes to investigate minor incidents’ (emphasis added), the following response is provided in that context.

We understand the need for the timely resolution of investigations and that this must also be balanced with the need to follow accepted procedures and processes (which exist for various legal and operational reasons). We are of the view that our investigation procedures are prudent and our responses to incidents are appropriate.

By way of illustration, following a safeworking breach (which may well be a minor incident):

  1. a preliminary assessment is conducted to identify all workers who may have participated in the breach/es;
  2. the relevant worker/s is/are then stood down from safeworking duties immediately (i.e. the worker/s is/are stood down from a particular role, which does not necessarily prohibit working in other areas or performing other roles). This is done as a precaution to protect other workers and the network from further possible safeworking breaches;
  3.  in addition, the relevant worker's safeworking roles are inactivated on their rail industry worker card (RIW card) pending investigation;
  4. the safeworking roles on the RIW card remain inactive while investigators simultaneously investigate what factors contributed to the incident, identify corrective actions and prepare a report. This allows the worker and/or their employer to undertake appropriate corrective actions, if required for a return to work;
  5. the investigation reports nominally take a week (7 days), however signoff can take longer. Given that the reports and corrective actions are developed simultaneously, the worker is normally back at work by the time the report is signed off;
  6. if a Contractor (or an employee of a Contractor) is involved, we hold the management of the inactivation of the safeworking roles and do not reactivate them until we are satisfied that appropriate corrective actions have been identified and implemented (where possible).

Please note that time can be consumed by:

7.  providing notice to a worker of an alleged incident
8.  receiving a considered (written) response from a worker in relation to an alleged incident; and
9.  delays in a Contractor identifying or implementing appropriate corrective actions as in point 6 above.

We are of the view that our investigations are carried out prudently and appropriately, and as is with our Safety Management System always open to continual improvement when necessary.

Regulator's response (Regulator 1)

The Office of the National Rail Safety Regulator (ONRSR) has reviewed the report, Australian Transport Safety Bureau (ATSB) Reference Number RR201300011, and we are satisfied with the response supplied by the operator.

We note the concerns raised by the reporter and the ONRSR will consider the content of the report for further planning of compliance activities within upcoming audits and inspections.

Last update 15 May 2015