Mode Rail
Reference No. RR20130002
Date reported 20 March 2013
Concern title Reducing safety standards
Concern summary

The concern related to the degrading of safety standards within the operation over the last four years and the oversight of the regulator in-to the investigation of incidents within the operator's network.

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

Reporter's concern

The reporter expressed a safety concern regarding the degrading of the safety standards within the operator over the last four years and more particularly the last two years. The reporter also expressed concern regarding the oversight of the regulator in regards to the investigation of incidents within the operator's network.

The reporter cites specific examples of their concerns including:

  • Permanent Way and Track Works: private contractors are used who have little knowledge of how to work near rail lines. Flagmen are sometimes absent or wrongly positioned and detonators are rarely used as a warning. This means that many drivers have come around a corner to find a crew working less than 400m away with many drivers experiencing near misses.
  • First Aid: First Aid qualifications are no longer kept up to date and so drivers are not qualified to assist passengers or work colleagues.
  • Maintenance: docking and maintenance turnaround times are reducing and more defects are becoming acceptable. Drivers are seeing defects that indicate a lack of planned maintenance, for example the increased number of defective pantographs which bring down overhead lines.
  • Train Controllers: Management have stated that they cannot find experienced Signallers, so they have hired and trained ex Authorised Officers. These controllers have received six weeks training and are active in the control room.

The reporter has given specific examples as follows:

  1. A train became entangled in the overhead lines. The driver of an opposite direction train heard a group call over the radio warning that there were emergency services putting out a grass fire and evacuating passengers, on the tracks ahead. This was not reported via the controller as required. The Driver was able to stop in time and avoid hitting police and fire officers on the track.
  2. Drivers reported an intruder on the tracks. The controller failed to issue a group call. The intruder was killed by an opposite direction train.
  3. The driver received a call from the controller asking whether the Home Departure into the single line section is OK. He confirms that visually it appears to be alright. As the train enters a short tunnel, the Train Controller requested his position on the line. Apparently they had lost detection on the single line section.
  4. A fatality had occurred that morning. Drivers were instructed to run as shuttles between two stations. Each Driver pointed out that it is illegal to shunt and re-dock a 6-car train at the station because there is no safe walking path and that extra Drivers would have to be sent to the station.
  5. A signal for the entry to a station was cycling through the aspects. The driver was told to wait until it showed a favourable aspect and then go through, instead of being issued with a Caution Order.
  6. Drivers encountered a defective signal in an underground Loop. The signal is located after a 55 curve and is virtually impossible to avoid going through without prior warning. The services should have been run direct while fitters repaired the blown bottom light. Instead, the signal was defective for over 12 hours and no-one was posted at the previous station to warn drivers.

Operator's response (Operator 1)

Response to specific identified areas of concern:

  • Permanent Way and Track Works: As per adherence to operating procedures and processes and following a review of the training program in 2012, new courseware was introduced in June 2012 with a mandatory requirement for all contractors to be retrained and certified in the new training programme before 30 June 2013. Anyone in the rail corridor must have the appropriate and valid Train Track Safety Awareness (TTSA). It should be noted that track access for works in the inner city area on lower speed tracks in multiple track areas do not use ATW, as it is unsafe to do so due to the flag persons not being able to safely cross tracks and reach a position of safety. In this situation flags / lights are used. New technology is also being investigated regarding improving approach viewing for train drivers. Additionally before a work group can access the Rail Corridor they are required to contact the Safety Centre to obtain permission to enter and work in the rail corridor. They have to provide information regarding the location and specific details on the works to be undertaken, and most importantly the proposed protection arrangements. Audits are conducted regularly and we send out a Train Services Officer (TSO) to any location where an incident is reported.
  • First Aid: It is no longer part of the driver training course, but it is briefly covered in the company induction. It was decided that it was not a requirement to achieve the accreditation for a certification 4. All 'Premium' Stations have qualified first aiders. Also in the Central Business District (CBD), there are St Johns Ambulance personnel located at train stations during am and pm peak hours. These additional identified actions contributed towards the decision that Train Divers did not need to be First Aid qualified.
  • Maintenance: In our view this statement is incorrect. We are seeing a reduction in defects and balanced maintenance has been identified to improve reliability.
  • Train Controllers: The current Train Controller structure consists of two distinct operator types, Train Controller 3 Grade and Train Controller 4 Grade (Signaller). A brief overview of the difference between the two is provided below:
    • Train Controller 3 Grade The Train Controller 3 Grade is the entry level grade for the Train Controller Coordinator structure. This Train Controller 3 provides an outer suburban network coordination function. The grade consists of 3 levels (Train Controller 1, 2 and 3) and promotion is achieved through experience, heightened skill level and an interview selection process.
    • Train Controller 4 Grade (Signaller) The Train Controller 4 Grade works under the instruction of the Train Controller 1, 2 and 3 grades for train running purposes. The Train Controller 4 manipulates signalling equipment in the "Clearly Defined Inner Suburban Area". It includes the main passenger terminal, but not the up and down main goods lines between [station] and [station]. There are separate recruitment strategies and training programs for the above two roles and can be provided in addition to this response upon request.

Response to specific examples supplied in the report

Given the lack of identifiable information provided with the specific examples we cannot advise on the organisation's course of action that was undertaken on any of the six examples supplied. We can confirm that all incidents that are reported and lodged in our incident management system are reviewed and where appropriate investigations are identified and undertaken, following our investigation procedures. We have a comprehensive Safety Management System (SMS) which receives extensive internal and external review under the requirements of the Rail Safety Act. The safety performance of the organisation has considerably improved in the last three years including significant reduction in Lost Time Injuries (LTI), and a significant increase in reporting of incidents and near misses, with maintained independent certification under ISO9001, ISO14001, ISO18001 and AS/NZS4801. The theme of safety in our organisation is driven by the internal safety program.

Our organisation takes safety seriously with a core company value being 'Safety' whereby we strive to promote the safety culture wherein 'no one walks past an unsafe act or unsafe condition' and this is communicated consistently and continually throughout the organisation.

Regulator's response (Regulator 1)

Recorded safety concerns:

1. Permanent Way and Track Works: We note the operator's response to the reported concerns and can confirm that the operator did implement a new training course way for the delivery of their Train Track Safety Awareness (TTSA). We can also confirm that the rail book of rules and operating procedures makes provisions for the non-use of ATW on the suburban network. We have conducted operational site compliance inspections at a number of the operator's track work locations during its 2012-13 compliance program. These operational site compliance inspections are also programmed in our 2013-14 compliance programs. It should also be noted that the operator is legislatively required to report all defined reportable railway circumstances (such as safe working breaches/irregularities) and railway accident or incidents to the Regulator, which is monitored for trends etc.

2. First Aid: We note the operator's response to the reported concerns and can confirm that it is not a rail safety legislative requirement.

3. Maintenance: We note the operator's response to the reported concerns; although we can confirm that the operator did experience electrical overhead and pantographs operational issues between 2010 and 2011. In April 2012 the operator introduced a Track Evaluation Vehicle directly under their operations, of which one of its purposes is to monitor electrical overhead condition etc. We have projected an infrastructure safety audit to be undertaken on the operator during its 2013-14 compliance program. In regards to rolling stock maintenance, we can confirm that in May 2011 the operator undertook a Train Fault Management Protocol (TFMP) Risk Based Review and in May 2012, they undertook a review of their Fleet Engineering Standards. In November 2012 the operator completed a Balance Fleet Maintenance Program. It should be noted that these maintenance changes were introduced by the operator in accordance with their legislative obligation under the prescribed Notification of Change provisions. We have projected a safety audit to be undertaken on the operator in regards to rolling stock maintenance during its 2013-14 compliance program.

4. Train Controllers: We note the operator's response to the reported concerns. We are not in a position to comment further as the occurrence data records do not report any safety trends that identify competency issues with the operator's signalling personal. It should also be noted that all the operator's trains controlled by controllers on the suburban network have robust engineering protections in place, such as 'train stops' located at signals.

In conclusions, we can confirm that the operator has a comprehensive Safety Management System (SMS) which during the 2012-13 compliance program (1 July - 30 June), the following compliance activities have been undertaken on the operator:

    • two rail safety audits
    • 9 rail safety compliance inspections; and
    • 11 rail safety inquiries/preliminary investigations.
Last update 24 March 2014