Fatal rail accident
On 8 June 2012 a New South Wales Coroner released findings into a 2010 fatal rail accident near Newbridge, NSW. The findings highlight safety concerns that require review by the rail industry in relation to the safety issues raised by the ATSB in its report released on 20 April 2012. During the course of its investigation, where safety issues were identified, these were communicated to interested parties for safety action.
Those issues cover:
- Deficient TOA form
- Minimum training levels
- Inconsistent TOA procedure
- Use of non-authorised forms
- Elevated risk due to fatigue
Circumstances of the accident
At about 11116 on 5 May 2010 collision occurred between a scheduled XPT passenger train and a track-mounted excavator near Newbridge, New South Wales. The operator of the excavator was fatally injured. The ATSB Investigation established that collision had occurred even though the work group using the excavator was authorised to be on the track under a Track Occupancy Authority (TOA) and that work had commenced prior to site protection measures being put in place. The ATSB also found that the members of work group were relatively inexperienced and that their training had not specifically discussed the relevant hazards and protections when working under a TOA.
Safety issues
The ATSB found the following safety issues as part of the investigation. The Coroner's findings were broadly consistent with the ATSB's findings:
1. Deficient TOA
During the Investigation the ATSB found that the TOA form in use at the time of the accident was deficient as there was no provision to record critical information regarding the location and type of worksite.
Consequently, the Protection Officer and Network Control Officer incorrectly conclude that the train had passed beyond the limits of the worksite. The Coroner found that 'the TOA form was deficient and that there was a miscommunication between the Protection Officer and the Network Control Officer. The Coroner also found that there was a weak management system within the Network Control Centre.
Prior to the release of the ATSB report the Australian Rail Track Corporation (ARTC) made changes to their rules and procedures which included changes to the TOA to ensure there was provision to record critical information. The ATSB assessed this action as adequately addressing the safety issue.
2. Minimum training levels
During the Investigation the ATSB found that the track workers were not provided with sufficient competency based or structured on the job training in relation the hazards and required protections for working under the TOA at Newbridge.
Prior to the release of the ATSB report the ARTC advised that it had reinforced with Protection Officers its requirements for Work Method Statement TRA-001 (Access to and working on or about track). The ARTC's internal audit program had also been redirected to safeworking with a focus on reviewing safeworking documentation for compliance with ARTC Network Rules and Procedures. The ATSB was satisfied that the ARTC had initiated action to address this safety issue.
The Coroner found that the supervision and training of the track workers was inadequate, and that some work practices had become sloppy and which were not being sufficiently overseen. The Coroner also found that ARTC rules and protocols were not adhered to by the track working crew. In particular two of the work crew commenced work without being instructed to do so and without regulation protection devices being placed.
3. Inconsistent TOA procedure
During the Investigation the ATSB found that ARTC procedure ANPR-701 (Using a Track Occupancy Authority) was inconsistent in that it did not allow for a scenario that would otherwise be permitted, and intended, under rule ANWT-304 (Track Occupancy Authority).
Prior to the release of the ATSB report the ARTC advised that it had trained its employees in this particular scenario and will review the procedure to ensure that it is consistent with the training and the TOA. The ATSB was satisfied that the ARTC had initiated action to address this safety issue.
4. Use of non-authorised forms
During the Investigation the ATSB found that some ARTC maintenance contractors were using non-authorised reproductions of the ARTC's TOA form.
Prior to the release of the ATSB report the ARTC conducted extensive briefings with all employees and contractors to explain changes to the ARTC TOA that took effect in November 2011. The ARTC made clear that only the new form was to be used and provided books of forms to employees and contractors. The ATSB was satisfied that the action taken would adequately address this safety issue.
5. Elevated risk due to fatigue
During the Investigation the ATSB found that it was possible that at times throughout the Network Control Officer's roster, fatigue levels were conducive to performance degradation.
Prior to the release of the ATSB report the ARTC advised that it is applying continuous improvement processes to fatigue as it does with all safety related matters. Recent activities that ARTC completed in relation to fatigue management included:
- Revising ARTC's fatigue policy and procedure to include more detailed hours of work guidelines, and information to support managers manage potential fatigue related matters,
- Scheduling managers to attend a supervisors fatigue management training course. This course trains managers in identifying and controlling possible fatigue related risks. This training supplements existing fatigue management training for all employees, and
- Rolling out an awareness campaign that has included sending a letter and pamphlet about rest and sleep directly to employee's homes, posters for display at all worksites, and a new safety.
The ATSB noted that ARTC mangers develop rosters in accordance with the ARTC policies and procedures. Considering the ARTC's advice that the fatigue policy and procedure is to be reviewed along with additional training and awareness programs, the ATSB was satisfied that the Australian Rail Track Corporation has initiated action to address this safety issue.
The Coroner concluded that there was insufficient evidence that the miscommunication in relation to the TOA (see Safety Issue 1 above) was the result of fatigue or other work conditions.
The ATSB emphasises that it is essential that information critical to the safe implementation of a TOA be clearly communicated between the PO and the NCO. The ATSB also emphasises that it is also essential that workers do not access the track until all levels or worksite protection have been fully implemented.
ATSB investigations and coronial inquiries
Inquests are separate to ATSB investigations. There are differences in the ATSB's and the Coroner's conclusions with respect to this accident. However, as outlined above The Coroner's findings were broadly consistent with those of the ATSB.
The ATSB's report can be downloaded by clicking on the PDF link to the top right of this page. Feedback can be provided via the link provided.
The Coroner's report can be obtained from the Coroner's Court of New South Wales, contact details are available via the Coroner's Court of NSW website.