Mode Rail
Reference No. RR201900007
Date reported 21 February 2019
Concern title The concern related to a poor safety culture at the operator’s [Location] base
Concern summary

The reporter has expressed a concern regarding a number of poor safety practices at [Operator’s] [Location] base.

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

Reporter's concern

The reporter has advised that:

  • It is common practice for red cards to be removed from freight wagons without corrective action being taken in order to meet operational requirements. The reporter states that this practice is putting the safety of drivers and workers at risk.
  • There is no roster in place for [Operator] employees at [Location]. The operation works on an ‘on call’ system or verbal instructions which may then change with no warning. This results in up to three shifts per 24 hours, rather than three shifts being planned per 24 hours. Timesheets are manipulated by the operator to reflect a different working pattern to disguise the split shifts being worked over a 24-hour period.
  • There is either no alcohol policy, or is not enforced as no measures to raise or address staff consuming alcohol between split shifts is taken.
  • Internal training/certification is inadequate, with some workers receiving no more than one hour of training in total. Many workers are not qualified for the tasks they are performing, including conducting maintenance on vehicles.
  • The reporter further advises that on numerous occasions they have observed workers conducting maintenance on vehicles in between shunting moves without any means of radio communication advising their position/intention; and workers crossing rails under vehicles and between wagons, whilst shunting moves are ongoing.

The reporter is concerned that the lack of adherence to any safety procedures/policies will result in serious injury, or worse, to a worker if not rectified.

Operator's response (Operator 1)

The reported concerns of poor safety practices at our [Location] operation have been discussed and investigated with our [position titles]. [Location] site is operated and maintained by [Operator 2] and the [Operator] staff who work at the premises have all been inducted at the site and maintain the rolling stock on behalf of [Operator 2].  [Operator] is extremely concerned and disappointed about the allegations of poor safety practices and have responded to each item separately and disprove each item.

It is common practice for red cards to be removed from freight wagons without corrective action being taken in order to meet operational requirements.

Our maintenance staff are qualified and experienced Wagon Maintainers who understand the “green/red card” procedure that the rail industry operates to and that you cannot remove a red card on a wagon until the fault has been rectified. If this alleged practice existed then this would have been reported by [Operator 2]. Further, this alleged practice would put our Company’s reputation and continued viability at major risk.

There is no roster in place for [Operator] employees at [Location] and timesheets are being manipulated to disguise the split shifts.

There is a roster in place for the maintenance staff which also addresses any possible fatigue issues. The roster recently had a vacancy and the existing staff have had to work split shifts for a short period to meet the operational requirements of wagon arrivals and departures. There is a sufficient rest break between the arrival and departure times to ensure that there are no fatigue issues. The staff are also advised directly by [Operator 2] operations if any trains are arriving late so they do not come in early waiting for late running trains. The [Location] [Operator] staff have refuted the allegation that timesheets are being manipulated.

There is no alcohol policy or any measure to address staff consuming alcohol between split shifts.

[Operator 2] have an Alcohol and Drug policy in place, and [Operator] also has a Drug and Alcohol Policy and a detailed Drug & Alcohol Management Plan, approved by ONRSR. All rail safety workers are aware of the requirement to have a zero blood alcohol reading, via mandatory training as part of company induction, as well as ongoing awareness training on a regular basis. In addition, all staff are subject to random alcohol and drug testing.

Internal training/certification is inadequate and many workers are not qualified for the tasks they are performing.

All [Operator] [Location] staff are trade qualified and have attended a Train Examination course run by a registered training organisation. The nationally recognised units of competency they are qualified in are:

  • TLIB2022 – Diagnose and rectify minor faults
  • TLIB3018 – Conduct full train examination
  • TLIB3019 – Test train braking system
  • TLIB3021 – Conduct train roll-by inspection

[Operator] also provides training in additional wagon elements as per the company training matrix, conducted by our internal experienced and Cert IV qualified Trainer, with refresher training conducted every two years.

Workers conducting maintenance on vehicles in between shunting moves without any means of radio communication plus worker crossing rails under vehicles and between wagons whilst shunting moves are ongoing.

[Operator 2] conduct all shunting operations in their yard and have procedures on shunting and working on rolling stock. All personnel are aware that you cannot conduct any maintenance work on vehicles in between shunting moves and that the crossing of rails under vehicles and in between wagons whilst shunting moves are ongoing is prohibited. If this alleged extremely dangerous practice existed then this would have been reported by [Operator 2] to [Operator]. All [Operator] staff use portable radio communications when working in the [Location] yard.

Lack of adherence to any safety procedures/policies will result in serious injury, or worse, to a worker if not rectified.

[Operator] has a robust and detailed Rail Safety Management System in place approved by ONRSR and it takes pride on its excellent safety record across its national footprint. All our staff are aware of the dangers involved in working in a rail environment with moving rolling stock. We have a designated incident reporting program and share all reported safety incidents, near misses and hazards with our staff to increase awareness and learnings across the business, plus we provide monthly presentations of Rail Safety Policies and Procedures.

Operator's response (Operator 2)

[Operator 2] have now completed its investigation into the REPCON complaints that you referred.

[Operator 2] has no record of any safety issues as alleged by the reporter having been brought to [Operator 2’s] attention.

[Operator 2’s] enquiries unearthed no evidence to support any of the alleged breaches raised by the reporter as having occurring at [Operator 2] [Location].

Please inform the reporter, that the reporter was inducted to [Operator 2] and contained within this induction was the requirement to report all incidents, injuries, near misses and hazards to [Operator 2]. 

Because the reporter has not reported their complaints to [Operator 2] this has prevented [Operator 2] being afforded the opportunity to objectively investigate any unsafe activities as alleged by the reporter.

[Operator 2] is disappointed that we have once again been forced through no fault of our own had to expend value resources and time to investigate unfounded complaints.

[Operator 2] contend the reporter should have been asked by the ATSB if they had brought their complaints to [Operator 2’s] attention for investigation, when this occurred and what [Operator 2] had advised the reporter was the outcome of the investigation.

[Operator 2] further contend that if a reporter is unable to provide answers to these three important questions that the REPCON complaints process should not be exercised.

[Operator 2] consider the use of the REPCON complaints system in this instance to be a misuse of the REPCON process.

[Operator 2] will continue to monitor our rail operations in accordance with our Safety Management System.

ATSB comments:

The ATSB provided the following feedback to Operator 2:

  • The ATSB reiterates that the ATSB’s Confidential Reporting system (REPCON) is not a ‘complaints’ process. It is a system for individuals to raise safety concerns confidentially. The ATSB raises these concerns with the people or organisations best placed to address the concern, in this case [Operator] and [Operator 2]. The ATSB discourages organisations from viewing REPCON reports as accusations of wrong doing that require justification.
  • Voluntary and confidential reporting systems are globally recognised as a necessity in mature safety systems. Confidential reporting systems have been implemented in a number of safety-oriented industries including: aviation, medicine, oil and gas, and rail. The Confidential Reporting for Safety (CIRAS) in the UK and the Confidential Close Call Reporting System (C3RS) in the United States are examples of equivalent established confidential reporting systems.
  • [Operator 2] appear to have some concerns that the reporter has reported directly to the ATSB rather than submitting an internal report. Information about safety-related risks can come from a variety of sources, and sometimes these sources are external confidential reports. Independent and non-punitive confidential reporting systems may be used to identify system vulnerabilities and gain a better understanding of the root causes prior to an incident or accident occurring. Confidential reporting data is complementary to the data generated by mandatory, statistical, and organisational monitoring systems.
  • The ATSB encourages all organisations to welcome REPCON reports, by viewing them as another tool that provides the organisation an opportunity to continually review and improve safety systems.
  • A report made to a confidential reporting system does not make the report any less valid if not also appearing in an organisation’s internal reporting system.
  • [Operator 2] has expressed disappointment in being forced to investigate unfounded complaints. Organisational safety reporting cultures tend to be sensitive to any perception other than whole openness to receiving any kinds of reports, even if they are deemed insignificant at the end of the day. As such, if a reporter is not comfortable reporting a safety concern through an organisation’s internal reporting mechanism for whatever reason, the ATSB encourages reporters to utilise the ATSB REPCON scheme.
  • The protection of the reporter’s identity is the primary element of the REPCON scheme and legislated accordingly in the Transport Safety Investigation (Voluntary and Confidential Reporting Scheme) Regulation 2012 (REPCON).  If the reporter has previously reported a concern to any organisations involved, or to the regulator, the protection of the reporter’s identity may be jeopardised. Accordingly, the concern may not be able to be progressed through the REPCON scheme.
  • The REPCON legislation outlines the requirements for ATSB to accept confidential reports. The requirements include, but not limited to, the ATSB reasonably believing the report to be true.

Regulator's response (Regulator 1)

ONRSR has reviewed the report including the reporter’s concerns, the response from [Operator] and also the accredited rail transport operator, [Operator 2].

One of the key functions of ONRSR under the Rail Safety National Law (RSNL) is to monitor a rail transport operator’s safety management system implementation and safety performance. ONRSR does this by using a risk based approach to the planning and conduct of a national work program of regulatory activities.

ONRSR can confirm that the matters raised in this REPCON report will be considered in the planning and conduct of further regulatory activities as part of the 2019 national work program.

Operator further comments:

Operator 2 subsequently reiterated its original concerns with the REPCON process and that Operator 2’s belief was that the reporter’s motivation was industrial related.

Last update 23 September 2019