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Mode Rail
Reference No. RR201500005
Date reported 07 May 2015
Concern title Safety culture within the organisation
Concern summary

The concern related to the safety culture within the operator leading to employees being too afraid to speak out about safety.

Industry / Operation affected Rail: Passenger - metropolitan
Concern subject type Rail: Operations

Reporter's concern

The reporter expressed a safety concern relating to the safety culture within the organisation.

The reporter has advised that this is shown in a number of different ways such as:

  • the non-compliance with the requirements of reporting Category A incidents to the ATSB (a number of incidents are recorded in their Incident Registry which should have been Immediately Reportable Matters but have not been reported)
  • significant pressure being placed on people to change findings detected during safety investigations and audits
  • findings being closed by senior management without the appropriate corrective action being recorded as having been taken
  • people, without the appropriate qualifications, are being tasked with conducting safety audits in areas which are used by the travelling public
  • the management team has had a number of changes which has reduced the overall knowledge and experience of safety related issues.

The reporter has advised that the legislation requires an organisation to promote and maintain a positive safety culture, but with the recent changes to senior positions, workers are reticent to speak out about safety concerns for fear of losing their position.

Operator's response (Operator 1)

As you may be aware, we are the current operator of the [operation] where we operate a small number of [rail vehicles] under contract to [operator]. This contract will expire on 30 June [year].

In December [year], we, as a member of a consortium, were awarded a contract to operate and maintain the existing network and once built incorporate a second network. The new contract has set much higher standards and expectations for the operation and maintenance, including safety, of the operation. Consequently, a number of strategic decisions have been taken, to ensure it can meet these obligations.

While we are the current operator, there are a number of changes that flow from the change in contract arrangements, which take effect from 1 July [year].

These changes include:

  • changes in parties undertaking maintenance activities
  • changes in the scope of rail safety activities undertaken by the organisation - some maintenance activities will be outsourced from 1 July [year] and rail safety accreditation will gradually migrate to the another organisation
  • changes in the organisation’s structure - we are seeking to leverage off the broader capability of the our larger parent organisation and globally, as well as make the changes which reflect the activities required under the new contracting environment
  • changes in capability - the new arrangements mean that we need greater capability and different functionality than has previously has been the case.

Following the contract being awarded to us, we have undertaken a review of our organisational structure.

This restructure meant some new roles were created, some existing roles merged and unfortunately, some existing roles were abolished resulting in a small number of individuals being made redundant.

These changes and change management processes are outlined in our safety implementation plan.

From the start of the transition, we initiated consultation, which included one-on-one discussion and staff events, to ensure everyone in the organisation was kept abreast of the transitional activities and importantly the changes likely to affect different roles within the organisation. In the specific instance of the safety function, we took an additional two-month period before arriving at a decision on the future resourcing that requirement. During that time we:

  • took time to understand the tasks being undertaken currently versus those required in the future
  • had informal dialogue with the Office of the National Rail Safety Regulator (ONRSR) and [operator] who both expressed concerns about the performance of individuals and the safety function generally, and
  • examined more broadly, what safety resource was required and where we might source that resource.

As a result, we have restructured our safety team. There are a number of roles which have been abolished, and the individuals themselves were made redundant. While we appreciate that this has been a challenging time for those individuals, it was imperative that we make such changes to ensure our organisation is fit for purpose in our 'new world'.

We are committed to continuously improving our safety performance and creating a working environment for our employees and contractors where safety is valued above all else.

While we note that safety culture can be seen through different lenses, we have implemented a number of initiatives to foster a positive safety culture. Two specific examples include our signal passed at danger (SPAD) reduction program and a hazard awareness campaign encouraging staff to report hazards and near misses.

In addition, we are taking a clear and strong line with respect to safety incidents where individuals have wilfully breached safety policies or procedures or have repeatedly breached safety policies or procedures.

These initiatives are now seeing positive trends, SPADs have reduced and hazard and near miss reporting has increased considerably. The increase in self-reporting of hazard and near misses has only been achieved by having a no blame culture.

Other indicators such as lost time injuries have remained at zero since June 2014, overall customer satisfaction has reached its highest rates since May 2013, and in a number of other areas, our performance is showing clear signs of improvement.

In regards to the de-identified report, we do encourage robust discussion with our investigators, only to ensure we identify all the contributing factors to make sure we have the right information to take corrective action. I believe on this instance, it relates to a discussion where by one of our engineers requested the contributing factors of an incident be broadened to include other information that came to light after the draft report had being finalised. The information was very technical which may have been difficult for an assisting investigator without an engineering background to understand. There was no consensus between the two on this particular investigation and the final decision was left to me. Given the technical experience of our Chief Engineer and the evidence and rationale provided, I, as the manager responsible for safety, chose to include the information in the report for completeness.

 

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 RR201500005.

The Report was received just prior to a planned compliance inspection with the operator. As such, areas of concern expressed in the report were included within the scope of the compliance inspection.

Please see below regarding reported concerns that were individually examined within the mentioned compliance inspection:

  • the non-compliance with the reporting requirements of Category A incidents to the ATSB (a number of incidents are recorded in their Incident Registry which should have been Immediately Reportable Matters but have not been reported)
  • findings being closed by senior management without the appropriate corrective action being recorded as having been taken
  • people without the appropriate qualifications are being tasked with conducting safety audits in areas which are used by the travelling public, and
  • the management team has had a number of changes which has reduced the overall knowledge and experience of safety related issues.

The compliance inspection, in general verified the implementation of the operator's safety management system.

While specific issues could not be substantiated, a number of related areas for improvement have been identified.

The issues not examined will provide intelligence for our ongoing management and engagement with the operator.

ATSB comment

The ATSB questioned the ONRSR on whether the Category A incidents had been reported. The ONRSR responded that this could not be verified, but the ONRSR has included this concern in their audit and compliance work program with the operator for 2016.

 
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Last update 22 December 2015