The reporter expressed a safety concern regarding repeated breaches of safe work procedures in the [Location] region.
The reporter advised that some employees and contractors at times deliberately violate work on track authorities, presumably because the individuals do not believe there is a risk to safety in doing so. When these breaches are correctly reported by other members of the work team, the reporter states that little is done to rectify or mitigate the risks.
The reporter stated that performance management and accountability of individuals who deliberately disregard safety is inadequate and not reflective of a just safety culture, in which intentional violations of safety procedures should not be tolerated.
The reporter further stated that work group leaders, who first receive the reports on the safe work breaches, lack the industry specific and safety knowledge to comprehend the potentially catastrophic consequences of breaching safe work procedures. As such, some work group managers do not respond to these reports adequately.
Reporter’s comments: ‘I have been working in the rail industry for many years, and due to a number of fatalities and serious injuries, workers fought hard to implement change, which resulted in the safe work procedures we now have today. To see the procedures treated with such disregard by individuals who have never seen the results of not having the procedures, is extremely frustrating.’
Operator's response (Operator 1)
In addressing this response, it is noted that there is insufficient information to allow [Operator] to undertake an investigation. [Operator] seeks any further detail that can be provided whilst respecting privacy, to allow investigation and if founded, prevent any reoccurrence of this alleged behaviour.
[Operator] has systems defining the way in which events are reported and investigated, with deliberate intent to understand systemic failures and how to prevent recurrence of similar events through the development of systemic fixes within our management systems. Improvement to our management systems is documented within [Operator’s] three-year safety strategy and has led to a streamlined process for reporting and investigation utilising the Incident Cause Analysis Methodology.
As a result of consultation with teams, there has been a focus on the importance of reporting and pathways that can be taken as a result of the following investigation. This improvement has led to increased reporting of incidents, near misses and hazards, allowing escalation to line leadership for visibility and intervention as well as implementation of preventive controls. [Operator] also shares lessons learnt from events across the business to facilitate learning across the business.
[Operator] Systems to support Reporting and Investigation
Through investigation, [Operator] is able to identify absent and failed controls as well as individual and team actions that contribute to an event. It is however desired that a systemic contributor or any contributing organisational factors are identified. This allows introduction of controls to target cultural change as a result of learning identified through investigation. This approach differs from traditional investigations that have occurred, that pass blame and finalise with discipline and counselling or retraining the worker in the rules or procedures. This has created tension with members of the organisation that are anchored to blame. It has been identified that having a blame or disciplined focus investigation system, breeds a culture of fear and non-reporting.
A further tactic integrated within [Operator’s] three-year safety strategy is just and fair culture. Any controls that are implemented targeting individual and team actions, is aligned to [Operator's] just and fair culture decision tree. As a result of investigation into safe working incidents, some examples of corrective actions include discipline ranging from immediate suspension of safe working roles and exclusion from Protection Officer duties, to longer term suspension or blocking of roles or access, removal from the work place and termination of employment.
Safe working rules and procedures form a fundamental set of controls to maintaining separation between trains and track workers on our network. Any deviance or breach, once reported, are investigated and acted on immediately. Over the past 12 months, the [Location] business unit has investigated over 50 events where potential breaches of rules or procedures were identified.
Systemically, safe working incidents and near misses that may or may not have resulted in a breach of the rules has resulted in numerous investigations to identify the systemic issue. Once investigated and contributing factors have been identified, numerous examples of action have been taken. There are examples of where this change has been triggered by events that have occurred within the [Location] Business Unit. Examples of action includes information shares clarifying requirements set out within the network rules and procedures, suspending the use of some forms of track access, safe notices requiring the implementation of increased controls for some forms of track access and changing the rules themselves. Further consideration into engineering controls including electronic track worker and location validation tools are currently underway and move beyond blame focused toward an individual.
Further reporting is encouraged, and the importance of reporting reinforced at numerous forums including [Location] Safety and Environment Day, and [Location] leadership sessions. Work Group Leaders specifically have attended these sessions and are encouraged to report any event, be it incident, near miss or hazard within one hour to their leader.
ATSB comment: The policies outlined to support incident reporting and subsequently identify strategies to mitigate safe working breaches, appear to be comprehensive and extensive. The ATSB is fully supportive of [Operator’s] strategy for a fair and just culture. It is further encouraging to read that [Operator’s] incident reporting has seen an increase of reports and that lessons learnt from these reports are fed back across the organisation to ensure others have an opportunity to gain knowledge and understanding of operational problems in a complex system, and assist with an effective process for corrective actions.
The ATSB acknowledges that it is difficult to investigate specific incidents of alleged breaches when REPCON reports are de-identified. While an investigation into specific incident/s may be beneficial for the organisation, it is not an intended outcome of the REPCON scheme. Rather, a desired outcome would be for operators to review the concerns raised more holistically, and consider utilising the information provided to form part of organisational intelligence. As an example, if deemed appropriate, the concerns raised in conjunction with closed reporting systems, may assist an organisation in forming future decisions around monitoring, training/education/communication, procedures or risk controls.
Regulator's response (Regulator 1)
ONRSR has reviewed the reporter’s concerns and the operator’s response. The matters raised have been considered in the planning of regulatory activities that will be conducted in the [Location] region as part of the 2019 and 2020 National Work Programs.
The ATSB subsequently advised the operator and regulator for their intelligence purposes, that the safe working breaches were reportedly occurring at a team, and often, individual level.