The reporter advised that changes regarding work on track authorities were made to the NIB on 10 January 2019; however, staff responsible for implementing the changes were only made aware of the amended procedures 12 days later, via an email. Responsible staff were continuing to request work on track authorities that contravened the amended procedures as late as three weeks after the changes to the NIB were initially made.
The reporter stated that the email used to advise staff of the major NIB changes placed no emphasis on the safety critical nature of the content. In addition, there was no requirement for staff to acknowledge that they had read and understood the amended procedures. Additionally, there are no processes in place to provide training to those who are required to be familiar with the changes to work on track authorities, including contractors, who do not have readily available access to documents when in the field.
The reporter further advised there has been an increase in safe-working rules and procedural changes that do not undergo the appropriate scrutiny by those officers tasked with authorising and enforcing rules. The changes are being received on the day of operation with minimal or no consultation. This results in inconsistencies within the changes that lead to confusion between authorising officers and track managers, which ultimately undermines safety.
The reporter further stated that this concern has previously been raised with the operator, with no response or indication that any review of the processes regarding changes to documentation is progressing.
The reporter believes that current standards surrounding the consultation, dissemination, communication and education to staff regarding changes to safety critical information is grossly inadequate.
Operator's response (Operator 1)
Network Information Books (NIBs) are developed to provide infrastructure and operational information for [Operator] customers, network controllers, asset management staff and contractors. NIB’s are updated following either, any relevant infrastructure/ operational changes or if minor discrepancies have been detected. This is either done in accordance with the requirements of [document number] Configuration Management procedure, or from any internal or external notification. The change initiator contacts Configuration Management to advise of minor discrepancies in these documents via the provided email address.
Changes to a NIB’s text content or diagrams are prepared by the relevant change initiator and then forwarded to the relevant operations representative for checking. Once the content change has been reviewed and approved by a corridor representative, the changes are then forwarded to the Configuration Management team to update the relevant NIB. Configuration Management team then updates the master document/drawing and confirms with corridor operations representatives that the requested changes are correct.
Approval for the information update is in accordance with [number] Engineering Document Control procedure. A notification advice (SAFE or Train Notice) is prepared and distributed to relevant stakeholders accordingly.
Recent changes to [Operator’s] Network Information Books
On 10 January 2019, several minor changes were made to the Network Information Books that cover the [Location] region of the [Operator] Network. Due to the changes being minor, [Operator’s] Safety Management System requires a SAFE Notice be distributed to all relevant parties. The minor changes integrated in the NIB’s were published and communicated on 29 January 2019, as such were not applied until the 29 January 2019. The minor changes were contained to the information provided in the Network Information Books, there were no amendments imposed or required to [Operator] Network Safeworking Rules or Procedures.
The changes made to the Network Information Books were undertaken to support the continued safety improvement in the way the Network Safeworking Rule [reference number] Lookout Working is applied in the rail corridor. Investigations undertaken into near miss events identified the potential for an unsafe working environment. The NIB’s were updated to provide additional guidance to competent rail safety workers (Protection Officers) to undertake the safety assessment to determine if Lookout Working is an appropriate level of protection for work on track. As sighting distance, and associated warning time, is the major control to protect workers from approaching rail traffic, the NIB’s were updated to clearly identify areas in which there may be inadequate sighting distance or insufficient access to a Safe Place when only utilising one Lookout. This was not a change to the rule, but a supporting tool for the infield application of [reference number].
The physical identification of these areas within the NIB’s allows Protection Officers to have an easily accessible document that assists in the identification of hazardous locations when planning work in the rail corridor. This assists with the consideration of alternative safeworking methods of protection if the onsite assessment deems Lookout Working unsuitable. The amended changes were developed in consultation with Protection Officers who use these tools in the field.
Several SAFE Notices were issued advertising the improvements to the various Network Information Book's in relation to Lookout Working over recent months. However, after the latest areas were updated, it was identified that the wording "NOT PERMITTED" in the SAFE Notices and on the NIB's created confusion. Based on the review of the feedback, it was determined that the wording could be improved to reflect the purpose of the information being provided. The affected NIB’s have been updated and these changes communicated to relevant teams. The new wording "HAZARDOUS LOCATION" used in the NIB’s is aligned to that used by other rail infrastructure managers.
The changes incorporated within the NIB’s did not change the requirements of the [Operator’s] Network Safeworking Rules or Procedures. The changes support a competent rail safety worker to make a planning assessment prior to attending a site, it does not negate the requirement to undertake an onsite assessment and deem if a higher level of protection is required. Please note the recent changes to the NIB’s as described above were not safety critical changes, the changes provided additional reference information to assist competent rail safety workers planning work in the rail corridor.
With regard to the assertion that Safeworking Rules and Procedures are not communicated prior to publication, and are only received on the day of operation, [Operator] has comprehensive records of consultation, training and notification of changes. The consultation group for each change is a cross section of typical users, and all changes undergo a documented risk assessment. Training records are kept for all rail industry workers who receive training in changes to Safeworking Rules and Procedures. The effective date of change to Safeworking Rules and Procedures are advertised in advance by SAFE Notice or Train Notice, as applicable.
Regulator's response (Regulator 1)
ONRSR has reviewed the information supplied by the reporter and the response provided by the operator. ONRSR has made further enquiries with the operator regarding this matter and is satisfied with the operator’s response.