Rail safety issues and actions
Permissive Signalling System
Issue number: | RO-2014-016-SI-01 |
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Who it affects: | Rail Operators on Melbourne Metropolitan Rail Network |
Issue owner: | Metro Trains Melbourne |
Transport function: | Rail: Other |
Background: | Investigation Report RO-2014-016 |
Issue release date: | 06 July 2016 |
Current issue status: | Safety action pending |
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Issue status justification: | The ATSB is not convinced that the proposed actions are sufficient to prevent a recurrence of this type of accident. Until further information is provided by MTM that satisfies the ATSB that the safety issue is adequately addressed, the ATSB will retain the status of this safety issue as ‘pending’ |
Safety issue description
The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.
Proactive Action
Action organisation: | Metro Trains Melbourne |
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Date: | 06 July 2016 |
Action status: | Released |
MTM issued a Weekly Operational Notice on 28 July 2015 stating that the existing details contained in Section 3, Rule 1 of the Book of Operating Rules and Procedures 1994 are to be deleted and the attached details in Annex 6 incorporating an automated voicemail facility is inserted. The voicemail facility includes a recorded recitation of the Rule. Annex 6 requires train drivers to call a telephone number and record a message advising that they are at an automatic signal at Stop and will be proceeding past the signal in accordance with the requirements of Section 3 Rule 1 of the Book of Operating Rules and Procedures 1994.
ATSB comment:
The ATSB accepts that the voicemail facility acts as a means of alerting train drivers to the operational rules governing permissive working. However, the ATSB is not satisfied that this process sufficiently mitigates the risk of a similar accident. Accordingly, the ATSB issues the following Safety Recommendation:
Recommendation
Action number: | RO-2014-016-SR-38 |
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Action organisation: | Metro Trains Melbourne |
Date: | 06 July 2016 |
Action status: | Released |
The ATSB recommends that Metro Trains Melbourne consider additional risk mitigation measures to maintain train separation where the safeworking system allows permissive working.
Additional correspondence
Response date: | 02 November 2016 |
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Response from: | Metro Trains Melbourne |
Action status: | Released |
Response text: | MTM Response to Recommendation RO-2014-016-SR-038 |