Mode Rail
Reference No. RR201500004
Date reported 30 January 2015
Concern title The operator has not implemented safety actions which they had advised the ATSB they were going to implement in response to a safety issue identified in an ATSB investigation
Concern summary

The concern related to a safety action which the operator had advised the ATSB that they would implement to address a safety issue which was identified in an ATSB investigation.

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

Reporter's concern

The reporter advised that the operator has not implemented the safety action they proposed to take in relation to a safety issue which was identified in an ATSB investigation report.

Safety Issue

The safety issue related to the communication around the issuing of a Local Possession Authority (LPA).

The reporter advised that a procedure relating to the communication of essential information is consistently not being adhered to, due to rushed communications to implement LPA's on time. Often the LPA is advertised to commence only a minute or two after the last train. The focus is to issue the LPA on time rather than on safety critical communications.

Operator's response (Operator 1)

It is not possible to respond to the very general nature of some of the allegations in this REPCON, given that they do not provide any information that would allow us to identify when specific non-conformances had taken place.

In terms of the safety issue, we were under the impression that the ATSB's letter gave us 90 days to provide a response to the issue. We provided a response on [date] within this assumed time period. We have since clarified this issue with the ATSB, and there is agreement that the original ATSB correspondence on this matter contained some ambiguities.

Accordingly, the safety issue has only recently been issued into safety action management (SAM) for progression. It will be progressed and monitored via SAM. It should also be noted that work on track audio files, including those relating to Local Possession authorities, are already randomly monitored.

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.

The issue of communications and adherence to communications is a valid and ongoing safety issue. However without further detail it is difficult for the operator or ONRSR to investigate the alleged non-conformances.

Notwithstanding the above, the ONRSR's investigation activities include a review of communications (including adherence to communication protocols) as part of the investigation in to an incident.

Additionally the ONRSR conducts targeted inspections on all Rail Infrastructure Managers (RIMs) within this state, in order to examine communication issues including the implementation of the RIM's program of monitoring adherence to communications protocols.

We note the concerns raised by the reporter and the ONRSR will consider the content of the report for further planning of compliance activities within upcoming audits and inspections.

ATSB comment

After receiving this REPCON the ATSB has reopened this safety issue and the investigation team has been in contact with the operator involved. The ATSB will monitor the outcome of their response to ensure that the safety issue is addressed. 

Last update 30 July 2015