Reference number
Date reported
Published date
Affected operation/industry
Concern summary

Inadequate promotion of updated operational procedures and insufficient training to employees in relation to procedural changes.

Reporter's deidentified concern

The reporter has expressed a safety concern regarding the lack of training provided to employees and inadequate promotion of updated operational procedures.

The reporter states that {operator] has released approximately 270 operational document changes to their train crew since 01 January 2018. Each of these requiring the employee to read the document, interpret any changes from the previous edition and recall these in an operational environment. Of these 270 changes, 158 were Operational Procedure changes, 46 Operating Instructions (which by definition alter an existing operational procedure that then needs to be cross-referenced), and 63 Operation Notices. A further 120-odd Traffic Management Plans have also been released to employees that they are required to read and acknowledge their understanding.

The reporter further states that employees are often working to procedures that are out of date because they cannot retain the current information due to the frequency and amount of changes to safety critical documents. As mainline supervisors are not fully cognisant of all the changes, there have been multiple examples where they have incorrectly advised drivers to perform tasks such as: ignoring the requirement to perform a Brake Pipe Leakage Test when setting up a train on the mainline (in contravention to [operating procedure]); shunting CB wagons with ECP active on the train (in contravention of [procedure]), and; working trains into traffic with defective headlights or other equipment in contravention of [procedure].

The reporter has also advised that the majority of employees hired in the past four years have no experience with any other operators. The changing procedures are creating an unsafe situation where employees are operating to different procedures, and attempts by employees to seek clarification from supervisors results in further confusion due to supervisors’ knowledge of the procedures being out of date themselves.

The concept that the individual employee is left to sort the ‘wheat from the chaff’ with no guidance or training from the company is not only completely unreasonable, it presents a serious safety concern.

Named party's response

[Operator] acknowledges that a report has been received by the ATSB (REPCON Report No. RR201800031) describing a safety concern in the operation of the [Operator’s] network. [Operator] does not agree with the reporter’s claim of a serious safety concern arising from the lack of training provided to employees and the inadequate promotion of updated operational procedures.

[Operator] confirms it has systems and procedures in place to control and manage documents and information relevant to the management of safety risks associated with its railway operations. It also has in place a system for training its personnel working on its rail network.

[Operator] advises that the issues raised by the reporter of REPCON Report No. RR201800031 should be viewed in the context of the following information and responds as follows:

  1. [Operator] acknowledges that there has been a significant number of changes to its rail operational procedures in the last few years, giving rise to the need for increased communication to rail teams. Many of these changes have been as a result of [project details]. Some of the changes, however, have also been due to the various projects undertaken to improve performance of the rail network, eg. following an incident. As projects mature, the rate of change to operational procedures should decrease.
  2. [Operator] has not been made aware of multiple examples of operating procedure breaches creating a safety concern, resulting from the frequency and number of changes to safety critical documents, as claimed by the reporter. All notifiable occurrences are reported to the Office of the National Rail Safety Regulator in accordance with relevant rail safety legislation. Of the notifiable occurrences involving a breach of an operational procedure (representing less than 4% of all notifiable occurrences during 2018) there is no evidence that the number or frequency of changes to the operational procedures during the year was an essential or contributing factor to the breach.
  3. The figures quoted in the REPCON report broadly correspond to the total of all changes made to the entire documentation library, circulated to all of [operator’s] maintenance and operational teams, during the year. While there have been a significant number of changes, only a small proportion of these changes are directly applicable to a specific rail team. Importantly, the changes relevant to a particular team are self-explanatory and easily identifiable through the document title and unique numbering conventions. Further, publication of changes is restricted to a weekly release, undertaken at approximately the same time each week, to support the change management structure and promote a routine in the workforce. 
  4. [Operator] does not accept that its employees have no guidance or training by the company, which presents a serious safety concern. [Operator] also rejects the claim that mainline supervisors are not cognisant of changes to safety critical documents.
  5. Rail operational procedures and relevant changes are available at information kiosks located at all rail depots within the network. [Operator] also supports the distribution of this information through portable devices (ie. mobile phone or tablet) so that personnel can access relevant material anywhere and anytime (with information able to be downloaded onto the devices for access even when the device is offline or where there is no WiFi connection). This process also ensures that all personnel have access to operations procedural changes simultaneously.
  6. Line leaders/supervisors are equipped with the tools and reference materials required to guide their respective teams on how to comply with the latest operational procedures and necessary updates. The [operator] safety management system specifically mandates leadership time in the field, which drives and promotes regular consultation with team members, allowing any field based concerns to be addressed in a timely manner. 
  7. The existing training program for new employees, regardless of prior experience, involves the partnering of new team members with an on-the-job trainer (OJT) who instructs and mentors them based on an approved training plan. The training program is focussed on guiding and teaching new employees to locate and access relevant resources to support their compliance with the relevant operating procedures and notified changes.
  8. [Operator] is continually seeking to improve the operation of its rail network (including in relation to management of its operational procedures and associated documentation). As part of its focus on continuous improvement, a governance team will be established (with project working groups already formed and progressing projects) to review current practices and propose improvements, including in the area of management of [operator’s] operational documents and change management processes.
  9. [Operator] will also reiterate to its workforce that all workers have a duty to raise safety concerns to [operator] to ensure a safe system of work and to aid in the continuous improvement of its rail operations.
Regulator's response

ONRSR has reviewed the information contained within REPCON RR201800031.

It is noted that the response provided by the rail transport operator is comprehensive and acknowledges the number of changes recently, including the introduction of [project]. The granting of permission by ONRSR to [operator] to operate [train type] is the culmination of two and a half years of assessment of [project details] in three separate variations to accreditation.

Through regulatory activities and further enquiries, ONRSR has observed the availability of the information kiosks to assist in operating notice distribution for both track worker safety and shunting activities. [Operator] have provided detailed frequently asked questions for drivers and evidence of workshops for introduction of operational changes.

ONRSR is satisfied that there is sufficient evidence to demonstrate that at the time of this response, [operator] have systems to manage so far as is reasonably practicable, the risks associated with management of change including training and consultation with rail safety workers.