Mode Rail
Reference No. RR201400007
Date reported 24 June 2014
Concern title Operator’s response to the NSW Coroner’s recommendations
Concern summary

The concern related the network operator’s response to the Coroner’s recommendations in relation to an accident which occurred on the operator’s main line service in which a person was fatally injured when they fell from a platform and were struck by two separate trains.

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

Reporter's concern

The reporter expressed a safety concern in relation to the network operator’s safety management processes.

The reporter advised that the Deputy State Coroner made a number of recommendations in relation to an accident which occurred on the operator’s main line, in which a person died after falling from a platform. To date none of these recommendations have been incorporated into the operator’s work processes.

Recommendations 1 – 3 could be applied at little cost to the organisation and would significantly improve the safety of persons on platforms at night. The operator advised the regulator that they were investigating alternative methods of addressing the risk of intoxicated persons on station platforms, but to date nothing has been announced in relation to this.

The coroner recommended that the operator continue to work towards implementing track intrusion detection systems and forward looking radar devices for locomotives. Can you advise if this has been progressed in any way?

The coroner also recommended that a system based on Root Cause Analysis be incorporated into the operator’s investigation processes for deaths and serious incidents. Has this been incorporated to date?

Operator's response (Operator 1)

We conducted a thorough review of all of the Coroner's recommendations. A number of the Coroner's recommendations were rejected due to the impracticability or impossibility of their implementation.

The recommendations raised in the REPCON and the responses are summarised in the table below:

Recommendations and responses

1. We introduce a protocol for managing persons sleeping on platforms.

  • No protocol that can guarantee we could meet this obligation.
  • The number of incidents involving drug and alcohol affected persons is too high to put the envisaged measure in place.
  • Large numbers of stations are unstaffed or have less than 24 hour coverage.

2. The protocol include a direction that sleeping persons be checked at regular intervals (eg. every 30 minutes).

  • See response above.

3.  At staffed stations without security personnel at night CCTV is used to maintain regular surveillance of sleeping persons.

  • See response above.

4. We continue to work towards implementing track intrusion detection systems linked with the signalling system.

  • We cannot in the short term implement systems envisaged in this recommendation. We will continue to identify such systems and will commit to trialling products that show potential and are likely to meet the requirement in a cost effective fashion.

5.  We considered forward looking radar on locomotives capable of detecting large objects (human size or bigger) ahead of a train at a distance sufficient to allow a safe emergency stop to be made.

  • The stopping distance for locomotive hauled and electric passenger trains is too large for a radar system to reliably detect a target object and for a train to stop before reaching the object.

6.       We considered introducing a system based on root cause analysis to investigate all deaths and serious incidents occurring on its systems.

  • We did consider the introduction of such a system. However the existing processes for assessing / investigating fatalities were deemed adequate. Police attend and investigate all fatalities on the network and we provide requested assistance.

Regulator's response (Regulator 1)

The Office of the National Rail Safety Regulator (ONRSR) has reviewed the report, and we are satisfied with the response supplied by the operator. Additionally, in regard to the matter at hand we note the following:

  • Following the mentioned Coronial enquiry into the incident, The [NSW] Independent Transport Safety Regulator (ITSR) liaised with the operator in relation to its response to the enquiry's recommendations. The operator's response indicated that they had conducted a detailed review of the recommendations and had determined that the recommendations were not feasible to implement across the metropolitan rail network and were unlikely to prevent similar such incidents.
  • ITSR subsequently liaised with the operator on receipt of the above advice and pursued the consideration of any available alternative methods of addressing the risk of intoxicated persons on station platforms. The operator advised ITSR that, whilst it currently still held the view that their safety management system provides an appropriate level of safety risk control so far as is reasonably practicable, it intended to undertake a review of risk control strategies adopted by other organisations to deal with intoxicated persons on public premises.
  • Upon consulting with the operator, ITSR indicated that they were satisfied that they have appropriate rail safety management systems to manage its safety risks so far as is reasonably practicable. ITSR also advised that they would continue to monitor the operator’s actions to ensure that it maintains and where possible improves its management of rail safety risk wherever feasible and practicable.

ATSB comment

REPCON questioned the ONRSR as to whether:

1.  Operators can have different procedures for different types of stations, i.e. quieter station with managers and those without managers having different procedures to busy inner city stations.

2.  How long ago did the operator advise that they were going to undertake the review of the other organisations’ procedures in relation to intoxicated persons and will ITSR be following up with the results?


ONRSR response:

1.  In reviewing and responding to the Coroner’s recommendations, the operator determined that it was not feasible to implement such practices across the network.

Furthermore, the operator identified that the effectiveness of the recommendations in preventing similar incidents may be limited.

2.  In March 2013, the operator advised that they would undertake the review, whereby; a summary of that review was forwarded to the Minister with a copy also disseminated to ITSR. The mentioned correspondence was dated June 2013. Additionally, the operator provided further advice in July 2014, indicating that they are currently reviewing their customer service training curriculum. The review will also include consideration of their current methods of dealing with intoxicated customers.

Last update 15 May 2015