Mode Rail
Reference No. RR201800008
Date reported 08 June 2018
Concern title Poor safety culture following organisational restructure
Concern summary

The concern related to disregard for safety, specifically in relation to fatigue management of employees, poor maintenance of locomotives and rolling stock, and training and qualification of train crews.

Industry / Operation affected Rail: Rolling stock
Concern subject type Rail: Policies & Procedures

Reporter's concern

The reporter has expressed a concern regarding the declining safety culture at [Operator] following a recent restructure of the organisation.

The reporter stated that there is a disregard for safety, specifically in relation to fatigue management of employees, poor maintenance of locomotives and rolling stock, and training and qualification of train crews.


The reporter states that while an accurate record of crew hours are maintained for payroll purposes, the operator is maintaining a duplicate record of crew hours, which is manipulated and/or falsified when entered into the fatigue management system to ensure an acceptable fatigue score is generated.  It is this set of time recording logs that are being supplied to the Regulator for auditing requirements, which does not reflect the regular shifts, which exceed the maximum hours permitted under the Rail Safety Act.


The reporter states that the minimum maintenance standard required of locomotives and rolling stock is not being carried out and that the condition of some equipment is very poor. Wheel condition, air brake cut outs, brake piston travel, body damage and defective handbrakes being a particular concern. The reporter further states that mechanical and electrical issues along with environmental issues such as overflowing waste sumps and water leaks are not being addressed. The reporter further advises that trains are not being correctly inspected before departure. Locomotives are also routinely operating without sand, which is critical to their adhesion systems and drivers are being exposed to trains regularly stalling on gradients as well as the associated safety risks.

The reporter advised that [Operator] is currently operating locomotives with critical safety defects such as defective horns, windscreen wipers, lighting and brake valves despite train drivers raising concerns about driving them on a regular basis. Logged locomotive repairs are not being carried out and safety critical defects are not being addressed.

Training and qualifications

The reporter is concerned about the lack of training and certification of employees across a number of areas, and stated that:

  • experienced train crews have not been re-certified in train inspection for excessive periods
  • many staff that commenced their career at [Operator] have not been correctly trained or qualified to inspect trains
  • crew’s route qualifications are often out of date with no paperwork to support them. In some cases, train crew have been qualified for routes without proper assessments; and
  • drivers are operating trains on routes where their qualifications had lapsed many years prior.

Reporter comment: “these safety breaches will result in a serious injury, or worse, if not rectified”.

Operator's response (Operator 1)

We are continuing to investigate the individual items in the ATSB REPCON report. Once completed, the outcomes will be shared with the [Operator] management and the ONRSR. Following this presentation of findings to [Operator] management we will embed any agreed actions into our current People Program.

Regulator's response (Regulator 1)

The Office of the National Rail Safety Regulator (ONRSR) has reviewed the contents of REPCON RR201800008 including the response by the rail transport operator. ONRSR is planning regulatory activities that will include the issues raised within this REPCON in the scope. Following completion of those activities, ONRSR will provide an update to ATSB.

Last update 05 August 2019