Investigation number
RO-2015-002
Occurrence date
Location
Guildford
State
Western Australia
Report release date
Report status
Final
Investigation level
Systemic
Investigation type
Occurrence Investigation
Investigation status
Completed
Occurrence category
Accident
Highest injury level
Fatal

Safety summary

What happened

On 10 February 2015, a Public Transport Authority (PTA) maintenance crew commenced work at Meadow Street, Guildford, Western Australia. The crew’s assigned tasks included maintaining the pedestrian gates adjacent to the level crossing.

At about 1035 one of the track workers was struck by a Perth-bound suburban passenger train. The track worker sustained fatal injuries.

What the ATSB found

The ATSB investigation found that the PTA maintenance workers had not implemented any form of track worker protection at the work site. This was partially due to the PTA not having documented instructions specifying the level of protection required, preferring that track workers make their own assessment based on their knowledge of the Network Rules. The ATSB found that, under these arrangements, track workers could make an incorrect assessment, placing themselves at a greater risk of being struck by a train.

A review of the safeworking training provided to the track workers found that the training material did provide a suitable level of safe-working knowledge.

Following the occurrence, the toxicology report on the deceased track worker identified the presence of amphetamine and methamphetamine; methamphetamine being a prescribed drug under the Rail Safety Regulations 2011. The use of stimulants such as methamphetamine is associated with a range of neurocognitive effects in humans that may affect performance.

The ATSB found that in this instance, the presence of a prescribed drug within the worker’s system appeared to be a relatively isolated case. An examination of the company’s drug and alcohol policy / procedures found them to be generally effective in managing drugs and alcohol in the workplace.

What's been done as a result

The PTA issued a safety alert following the incident to highlight the importance of implementing the correct level of track worker protection. The subsequent introduction of new safeworking rules, track access accreditation levels and training further supported this.

Further, the PTA has created the role of Workplace trainer and assessor with the task of ensuring track workers comply with the network rules by way of competency-based assessments. Implementation of a new track access accreditation system, with improved training and job mentoring, has also commenced.

Safety message

This incident strongly emphasises the need for rail transport operators to provide clear and concise work instructions to employees working within the railway corridor. It also highlights the potential for recreational and other drug use to impair performance and affect workplace safety.

Meadow Street pedestrian gate

Meadow St pedestrian gate
Source: ATSB

The occurrence

On the morning of 10 February 2015, Public Transport Authority of Western Australia (PTA) signal maintenance crews commenced duty at Claisebrook depot. The crews were arranged into teams according to their qualification and skill sets. One of these teams consisted of a PTA employee and two contractors. The PTA employee was a maintainer, but on this day, he was undertaking the role of the protection officer[1] to provide safe working protection to the contractors. One of the contractors, who had more experience on the PTA network, was assigned the role of signal technician while the other was allocated maintenance duties.

At about 0830, the team departed Claisebrook depot and drove to the Meadow Street level crossing in Guildford, WA. On arrival, the protection officer contacted train control and booked on-track[2]. The team then commenced work, where the protection officer cleaned and maintained the pedestrian gates while the signal technician and maintainer carried out electrical testing.

At about 1019, down[3] suburban passenger service 9571 approached the Meadow Street level crossing from the west. When the level crossing protection equipment (gates, lights and bells) activated, the maintainer noticed the north-west pedestrian gate was not closing completely. He advised the signal technician who, as train 9571 passed through the crossing, called the protection officer over to help assess whether the pedestrian gate needed adjusting.

Figure 1: Location map – Meadow Street level crossing, Guildford

Figure 1: Location map – Meadow Street level crossing, Guildford

At about 1032, train 9573 approached the Meadow Street level crossing from the west (Figure 1). The team, after again observing the operation of the pedestrian gate, decided to compare the control arm settings with the south-west pedestrian gate control arm. After train 9573 had passed through the crossing, the protection officer and the maintainer crossed the railway to the south-west pedestrian gate while the signal technician returned to the electrical location case. The level crossing protection equipment continued to operate because another train (9572) was approaching the crossing from the east, although it could not yet be seen. The maintainer mentioned to the protection officer that there was another train coming, which the protection officer acknowledged.

The protection officer and maintainer examined the south-west pedestrian gate control arm and agreed its adjustment was different to the north-west pedestrian gate. Meanwhile, up suburban passenger service 9572 continued to approach from the east. The driver of 9572 sounded the horn on approach to Meadow Street and noticed two people working on the track side of the pedestrian gates.

Moments later, the protection officer turned to his right, facing away from train 9572, and started to walk towards the track. The maintainer, who saw the train approaching the level crossing, called out a warning and attempted to stop the protection officer. The driver of 9572 saw the protection officer step towards the track and immediately made an emergency brake application.

At approximately 1035, as it passed through the crossing, train 9572 struck and fatally injured the protection officer – coming to a stop a short distance further along the track. The signal technician (at the location case) heard the collision and called out to the maintainer, who replied that the protection officer had been hit by the train.

Post-occurrence

The signal technician and maintainer immediately returned to their vehicle and contacted their supervisor. At the same time, the driver of 9572 contacted train control and advised he had struck a person at the Meadow Street level crossing.

All train services between Bassendean and Midland were suspended and the level crossing closed to traffic. The PTA, emergency services, WA Office of Rail Safety (ORS) and Worksafe WA attended the site.

At about 1200, the signal technician and maintainer were taken back to Claisebrook depot. Drug and alcohol testing was conducted – returning negative results.

At about 1300, train 9572 was moved to the Claisebrook depot for examination.

__________

  1. Protection Officer is a nationally recognised term to describe a person who provides worksite protection (RISSB Glossary of Railway Terminology 2010) and is used in that context throughout this report. At the time of this incident, a worker who held WPW15 accreditation was responsible for worksite protection, though the term Protection Officer was not used. As of 1 August 2015, the PTA introduced protection officer qualifications, which included additional safeworking training beyond that previously supplied under a WPW15 accreditation.
  2. Industry term used to describe contacting train control and advising them of the works to be undertaken at that location
  3. Trains on the Midland line travelling away from Perth are referred to as ‘down’ trains, travelling towards Perth as ‘up’ trains
Context

Location

Meadow Street level crossing is located in Guildford, Western Australia, about 13 km from Perth Railway Station. The level crossing consists of dual-gauge double-track railway over a dual carriageway road with pedestrian walkways on both sides. The crossing is immediately adjacent to the road intersection between Meadow Street and James Street. The road intersection is controlled by traffic lights, which work in conjunction with the level crossing equipment.

The PTA maintained the level crossing and associated pedestrian gates.

Track information

The track at Meadow Street was part of the dual-gauge line from Midland to East Perth; consisting of both narrow gauge (1067 mm) and standard gauge track (1435 mm) using a common rail. The track in this area was part of the Australian Defined Interstate Rail Network (DIRN).

The level crossing was equipped with boom gates, flashing warning lights and bells for road traffic. The pedestrian walkway included automatic gates and electronic alarms for pedestrian traffic, with a pedestrian escape route in the event that the gates closed while pedestrians were still crossing the track.

The Meadow Street level crossing used electronic approach and outer approach track circuits to detect the approach of trains from either direction on either line (Figure 2). When a train is detected on the approach, the control circuit causes the level crossing bells and lights to activate, and the boom gates to lower. In addition, the automatic pedestrian gates close and the pedestrian alarms sound. Due to the proximity to the James Street intersection, an indication is provided to the road traffic light control system to manage any traffic intending to turn into Meadow Street.

The purpose of the outer approach circuits is to prevent the level crossing boom gates from rising and descending in quick succession if a second train is approaching the crossing. If the level crossing equipment is already operating and a train detected on the outer approach, the boom gates remain lowered and the pedestrian gates remain closed until the second train has passed.

Figure 2: Diagram of Meadow Street level crossing, Guildford, WA

Figure 2: Diagram of Meadow Street level crossing, Guildford, WA

The level crossing bells and lights operate when trains are detected on the approach track circuits (shown in green). If the crossing is already operating, it will continue to operate if another train is detected on either the approach track circuits or the outer approach track circuits (shown in blue). Source: PTA amended and annotated by ATSB

Train information

The PTA operates two types of electric multiple-unit (EMU) railcars. The A-series EMUs (as involved in this incident) are comprised of two semi-permanently coupled railcars, which are 48.42 m in length and have a gross weight of 114 t. The railcars’ maximum operating speed was 110 km/h.

Train services 9572 and 9573 were suburban services, stopping at all stations and operating between Perth and Midland.

Event recorders

The A-series railcars were fitted with an Automatic Train Protection (ATP) system to reduce the risk of train drivers passing a signal at danger / stop. The system also provided digital recordings of train performance such as braking, power applied, speed, etc. However, the A-series were not fitted with dedicated event recorders. In addition to the performance elements described above, an event recorder typically records operation of other mechanical and control systems such as the horn; providing important information to aid in the analysis of a safety occurrence.

Train crew information

Train 9572 was operated by a single driver. At the time of the incident the driver was appropriately qualified and trained to operate A-series railcars over the Perth - Midland route.

Following the incident the driver was tested for the presence of alcohol and other drugs and the results were negative.

Maintenance team information

The signals maintenance team working at Meadow Street consisted of:

  • a PTA employee who was qualified in worksite protection and was working as the protection officer
  • a contractor qualified and working as a signal technician
  • a second contractor with qualifications of a signal technician but working as a maintainer.

All personnel had a safe working qualification allowing them to work within the rail reserve without supervision. The PTA employee (protection officer) had additional safe-working qualifications allowing him to provide worksite protection associated with working on or about the railway reserve.

Drug and Alcohol testing

Following the incident, the signal technician and maintainer underwent preliminary screening for the presence of alcohol and prescribed drugs. Both tests returned a negative result.

As part of the coronial investigation into the accident, a toxicology examination was undertaken on the deceased worker. The examination was unable to confirm the presence of alcohol, but amphetamine and methamphetamine were present in the samples tested. Methamphetamine is classed as a prescribed drug under the Rail Safety Regulations 2011 - the legislation applicable to the PTA’s operations at the time of the incident.

Environmental conditions

A weather report from Perth Airport (approximately 4km south of Meadow Street) showed the temperature at the time of the accident was about 27 degrees, with fine conditions and light winds.

As such, weather conditions were considered unlikely to have contributed to the occurrence.

Maintenance Tasks

The track workers’ task was to undertake maintenance of the level crossing and pedestrian gates at Meadow St. The signal technician and maintainer carried out electrical checks, while the protection officer conducted maintenance on the boom gates and pedestrian gates.

Pedestrian Gates

To facilitate maintenance of the level crossing equipment, certain tasks required the crossing to be operating while the work is being carried out. This work included tasks such as circuit testing and checks of the boom and pedestrian gate operation. In some cases, these tasks required the signal technician or maintainer to work close to or inside the danger zone[4].

One such task was the inspection and, if required, adjustment of the pedestrian gate closing mechanism. The gate control box was located inside the pedestrian escape, with the control arm running from the box to the gate on the track side (Figure 3) - about 3 m from the railway line.

A level crossing test switch[5] was provided at Meadow Street that can facilitate operation of the crossing equipment when trains were not present. Despite the availability of a test switch, it was common practice for maintenance personnel to rely on scheduled train services to facilitate operation of the crossing equipment for testing and maintenance of the pedestrian gates. At interview, signalling personnel reported a reluctance to use the test switch, in light of the view that it would (unnecessarily) close the crossing to road traffic. In addition, there was a slight difference in the operation of the pedestrian gates when initiated by the test switch (when gates would close under spring tension only) compared with normal operation when activated by a rail vehicle (when gates would close under a combination of spring tension and motor control).

Figure 3: General arrangement of south-western pedestrian gate

Figure 3: General arrangement of south-western pedestrian gate

The protection officer and signal maintainer reviewed the operation of the south-western pedestrian gate from the track side of the closed gate (within the danger zone). This examination placed the track workers in a position that was less safe than being within the pedestrian escape area or on the outside of the closed gate. Source: ATSB

Maintenance personnel advised that to assess or adjust the control arm required track workers to stand inside the three-metre danger zone. Some maintainers would carry out the task with the gate open, working in the escape area with the gate acting as a barrier to the track. However, it was evident that some other maintainers carried out the task when the gate was closed, in which case there was no barrier protecting them against inadvertently stepping onto the track.

The ATSB’s investigation found that the process for conducting maintenance on level crossing pedestrian gates varied between personnel. In the subject case, the workers adopted a process whereby the presence of a train was used to operate the level crossing equipment and maintenance and/or adjustment of the gate control arm was undertaken while the gate was in the closed position. This process meant that workers would be positioned within the danger zone, and focused on the maintenance task, at a time when trains were present, and without a barrier between themselves and the track.

Worker safety and worksite protection

The safety of personnel working on and around operating rail services is achieved through a number of complementary measures. These fall into two general areas:

  • Worksite protection

These are the measures put in place to mitigate the risk of injury from railway operational hazards. That is, ensuring separation between track workers and train operations.

  • Worker safety

These are the measures put in place to mitigate the risk of injury from site-specific hazards and task specific hazards.

Worksite protection

To keep track workers separate from rail traffic, rail systems within Australia use various methods of safe working. The higher levels of protection involve exclusion of rail traffic from a worksite and can include the complete closure of the railway (or part thereof). The lower levels of protection permit work to be undertaken between train services and can use other employees to warn track workers of approaching rail vehicles.

Access to maintain suburban railway networks is often more restrictive than for freight networks due to the volume and frequency of rail traffic. Works that require the railway to be closed, even for a short period, are generally only undertaken at night when the frequency of rail vehicles has reduced. Works carried out during the day are usually associated with general maintenance or inspection tasks that do not require closing the railway.

The PTA Network Rules document the requirements for providing worksite protection. It is routine for track workers to use Lookout Protection when working in the danger zone with hand tools only and with the ability to move to a place of safety prior to the arrival of any oncoming rail vehicle. Rule 191 documents the requirements for lookout protection.

The purpose of lookout protection is to task a person or persons to maintain a watch for approaching trains - allowing track workers to be suitably warned to stop work, move to a place of safety and allow the train/s to pass before returning to work. The PTA network rules define a place of safety as either:

  • Where there is at least 3 m clearance between the person and the nearest running line (rail);
  • Properly constructed for use as a refuge;
  • Where a structure or physical barrier has been erected to provide protection; or
  • Behind the safety line on a platform.

Under lookout protection, the lookout’s sole duty must be to maintain a constant watch for trains and no other work[6] may be undertaken. A lookout is only required when track workers are within, or likely to go within, the danger zone. Should the work be outside the danger zone, the lookout may perform other duties, however should track workers resume works within, or likely to go within the danger zone, the lookout must resume the exclusive lookout role.

In this occurrence, the ATSB found that the protection officer had not discussed the worksite protection method with the train controller or the contractors prior to commencing work. It was evident that the role of a lookout had not been allocated, as all three track workers continued to be engaged in maintenance tasks. At the time of the collision, the protection officer was involved with maintenance tasks rather than the assigned role of protection officer.

Worker safety

The PTA had implemented two levels of hazard assessment to ensure worker safety.

  • Job Safety Analysis (JSA) forms

Job Safety Analysis (JSA) forms were used to document and assess the risks inherent to conducting the particular job at hand. The JSA for Maintenance of Automatic Pedestrian Crossing Equipment provided information such as the number of people required to carry out the job, equipment and training required, and a risk matrix containing a selection of high level generic risks that should be considered prior to commencing the job.

In the context of this incident, the JSA identified ‘Being hit by a train’ as a potential hazard, with the associated controls identified as ‘Adherence to safety procedures - assign competent lookout, obtain prior train information (booking on-track)’.

  • Pre-start checklist

Pre-start checklists were used as a record that workers had considered all issues that ensure a task could be undertaken safely. The checklist is a generic form that can be used for any site or task and records information such as date, location, task and names of workers. The checklist records acknowledgment that workers have considered and understand the scope of work and the measures required to undertake the work safely, such as the information contained in the JSA.

The ATSB found that the site team, in this case, had not completed the pre-start checklist prior to commencing work at Meadow Street. While it is likely that the workers were aware of the JSA for pedestrian gate maintenance, there was no record that they had considered the worker safety risk controls contained in it.

Training

To work within the rail corridor[7] on a railway within Australia, operators and infrastructure owners mandate that personnel are trained and deemed competent in a suitable level of safeworking. The level of training and associated competency assessments, depend on the tasks that the person is expected to carry out. Operators and infrastructure owners typically include training as part of their safety management system.

The PTA network rules stated that all persons require an appropriate Track Access Permit, before entering the PTA railway reserve to undertake work at, or closer than 3 metres from the nearest running line or overhead traction power equipment.

The PTA Appendix to the Network Rules detailed the typical accreditation level required for various position types. The appendix considers a WPW15 accreditation level for the positions of safe-working technician, electrical fitter / maintainer, as well as track supervisor and / or flag attendant as a minimum. The document Instructions to Staff Engaged on Maintenance of Signalling Apparatus also stated that a signal technician must be in possession of a PTA accreditation permit to the WPW15 level.

A simplified safe-working accreditation, designated WPW05, was also available for personnel such as managers, engineers, trades, and technical people working within the rail corridor. However, the PTA rules, instructions and training material all specified that any person undertaking work on the track or associated infrastructure must have, as a minimum, an accreditation level of WPW15. A person with WPW15 accreditation must supervise a person who only has a WPW05 accreditation when that person carries out work.

To obtain accreditation for the PTA network, workers must complete specified individual courses pertaining to the accreditation level. A WPW15 accreditation required a worker to complete courses in Working on or around the Railway Track, Safety Instructions for the electrified area and Work Site Protection. The course Awareness for unaccompanied access to worksite provides the majority of the training, which includes a section on how act as a flagman when using Lookout Protection.

In this case, the protection officer had been trained (August 2012) and deemed competent at accreditation level WPW15. The signal maintainer and signal technician both had a WPW05 accreditation at the time of the incident, although the maintainer had completed the necessary training for WPW15 accreditation during the previous week.

It is unclear whether the PTA classifies maintenance on signalling equipment as ‘work on track’ or ‘work on associated infrastructure’. Whilst the work being carried out at Meadow St was predominately undertaken more than 3 m from the track, it is reasonable to consider any work involving signalling equipment is, of its nature, work on associated infrastructure.

Since this incident, the PTA has introduced a new system of safe-working accreditation. This system has removed the WPW05 accreditation level; replacing it with a more rigid tier-based process. The theory-based training will also comprise coaching and on-the-job mentoring, which will form part of the assessment of an employee’s competency. Under the new accreditation system, track workers will gain a greater understanding of track protection implementation and operation. The PTA was also planning to internalise safe-working training for all those who work on track, rather than using an external provider. This will provide the ability to monitor and control the quality of training and assessment provided to all workers including contractors. 

__________

  1. Industry term generally considered everywhere within 3m horizontally from the nearest rail and any distance above or below this 3 m, unless a safe place exists or has been created.
  2. Also known as a flagman switch or manual switch. Used for manually activating the level crossing.
  3. Work is generally defined as any activity within the danger zone other than walking directly from one side of the rail reserve to the other.
  4. Also known as the rail reserve
Findings

From the evidence available, the following findings are made with respect to the fatality at Guildford, Western Australia on 10 February 2015. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

  • Worksite protection had not been adequately implemented to ensure workers were protected against inadvertently stepping into the path of a train while undertaking maintenance work.
  • When maintaining automatic pedestrian crossing equipment, it was common practice for maintenance personnel to adopt a process that was inherently less safe than an alternative.
  • The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment. [Safety issue]

Other Safety Factor

  • The Protection Officer tested positive to a substance that may impair performance, however it was not possible to determine whether this contributed to the incident.

Other findings

  • The Public Transport Authority’s Alcohol and Other Drug policy was found to be comprehensive and compliant with legislative requirements
  • The Public Transport Authority A-series rail cars do not have a dedicated system that records events such as the sounding of the horn.
Safety issues and actions

The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

Depending on the level of risk of the safety issue, the extent of corrective action taken by the relevant organisation, or the desirability of directing a broad safety message to the rail industry, the ATSB may issue safety recommendations or safety advisory notices as part of the final report.

Documented Instructions

The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment.

Rail safety issue: RO-2015-002-SI-01

Purpose of safety investigations & publishing information

Purpose of safety investigations

The objective of a safety investigation is to enhance transport safety. This is done through:

  • identifying safety issues and facilitating safety action to address those issues
  • providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.

It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.

Terminology

An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.

Publishing information 

Released in accordance with section 25 of the Transport Safety Investigation Act 2003

Published by: Australian Transport Safety Bureau

© Commonwealth of Australia 2016

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Train Details
Train number
AEA239/AEB339
Train damage
Minor
Rail occurrence type
Collision
Destination
Perth, WA
Rail Operator
Public Transport Authority of Western Australia
Rail Operation Type
Metropolitan Public Transport