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

An amendment to policy that removed in-field protection for track machines operating within a Track Occupancy Authority

Reporter's deidentified concern

The report concerned an amendment to policy that removed in-field protection for track machines operating within a Track Occupancy Authority. 

The reporter raised a safety concern regarding proposed changes to policy, due to be implemented on [date], that will see all in-field protection for R1 and R2 track machines operating within a Track Occupancy Authority removed.

The reporter advised that the current procedures state that in-field protection, rail traffic signals (detonators) and/or red boards, must be in place at the limits of the Track Occupancy Authority, where the track is obstructed or otherwise made unsafe for rail traffic.

The proposed removal of all in-field protection enables track machines that are working clear of a set of points, to potentially reach a set of points without the machine operator receiving any prior warning. A train travelling at road speed could potentially reach the same set of points at the same time, resulting in a train to train collision.

The reporter queried what the rationale is behind the decision to remove the in-field protections and what, if any, assessments have been conducted to mitigate the risk of a track machine exceeding its limit of authority.

The reporter advised that due to the nature of work conducted on the track machines, operators are routinely looking at the ground, preoccupied with the type of work they are performing, and are often located at the rear or centre of the machine resulting in machine operators having a limited view of the track ahead.

The ATSB noted that there have been numerous instances where track machines have exceeded their limit of authority during work.

Named party's response

[Operator] has undertaken a thorough review of the concerns raised in the REPCON report and can provide the following comments in relation to these concerns.

The report refers to an element of [State] Network Rules and Procedures that is scheduled for publication on [date]. The amendment is not a material change to the work on track protection method, rather it removes an inconsistency that existed in[State] Network Rules and Procedures  for situations where work trains and track vehicles are permitted to work without in-field protection under an Alternative Proceed Authority (APA), however are required to place infield protection at the limits of a Track Occupancy Authority (TOA), even though a TOA is a higher level of protection.

When working under an APA:

  • there is no requirement for in-field protection
  • there is no minimum distance to the limits of the authority
  • all trains blocks are placed by the Network Control Officer (NCO) to protect the track section (which can be removed or overridden without codes provided by the Protection Officer (PO)
  • there is no ability to suspend or reinstate (increasing the NCO workload due to the time required to cancel and reissue new APAs).

When working under a TOA:

  • in-field protection is required at the TOA limits
  • if more than one worksite is created within the TOA, then infield protection is also required for each worksite
  • there are minimum buffer distances to the limits of the authority unless points can be set away to prevent the entry of rail traffic
  • coded blocking facilities are placed by the NCO to protect the track section (which cannot be removed without codes provided by the PO, or overridden until a supervised approval process has been completed and documented, and the override code is entered by the Supervisor).
  • TOA's can be efficiently suspended and re-instated.

During review of [procedure documentation] a risk was identified that workers in the field may be encouraged to perform work under an APA as it is easier to apply due to no in-field protection being required, whereas an APA should be used when a TOA cannot be applied or is not reasonably practicable ([procedures] makes the requirement for a PO to assess and plan protection, and to use a higher level of protection, if practicable).

The proposed amendment removes the requirement for in-field protection at the TOA limits only for single workgroups consisting of R1/R2 rated track vehicles and work trains. If there are multiple workgroups (i.e. separate work groups unassociated with the machines), or vehicles that do not reliably operate track circuits, in-field protection at TOA limits will still be required.

It should be noted that the risk of Signal Passed at Danger ( SPAD) by rail traffic exists in all aspects of operations for trains and track vehicles, however in-field protection is not intended to prevent events where working rail traffic exceeds the worksite limits. The worksite limits may or may not align with the TOA limits. Under a TOA, there is a requirement for the PO to either issue track vehicles a written instruction (SW50 with worksite limits outlined) or act as a pilot, and where the PO's safety assessment deems it necessary, delineate the worksite limits (bollards, flagging etc), to help manage the risk of vehicles exceeding their limits of authority when working.

Consultation of the proposed changes was undertaken across the organisation, with limited items of feedback concerning this aspect of the document, all of which were responded to with no further issues raised. Change management was undertaken in accordance with the safety management system with appropriate records available to demonstrate this.

The ATSB sought clarification from the operator with regard to the following points:

The Operator’s response states that when working under a TOA, ‘There are minimum buffer distances to the limits of the authority unless points can be set away to prevent the entry of rail traffic’. The ATSB notes that the buffer distance provides opportunity for recovery actions to be taken in order to prevent an accident, in the event of an error regarding workers or vehicles exceeding the limits of authority. The condition where the buffer distance is reduced due to points ‘…set away…’ suggests a potential increase to safety risk due to a reduced buffer distance. While it is acknowledged that in-field protection might not be intended to prevent workers exceeding the worksite limits, the in-field protection still provides workers a visual indication of their worksite limits.

The response states that when working under an Alternative Proceed Authority (APA), ‘There is no requirement for in-field protection’. However, the ATSB understands that under an APA, there is a requirement to place stop signs at the entry end limit, where there are no signals for a reverse direction movement. Consequently, it would appear that both an APA and the previous TOA requirement give provision for a visual indication of the worksite limits.

The response further states that the intent of the rule change was to remove an inconsistency related to work trains and track vehicles working under either the APA or TOA rules. A [Operator] review identified that ‘…workers in the field may be encouraged to perform work under an APA as it is easier to apply…’, rather than use a TOA which provides ‘…a higher level of protection’. However, the ATSB notes that [Operator’s] proposed solution appears to introduce another risk as it seeks to ‘reduce’ the level of protection required under the TOA rules. The reporter’s note that the amendment has been assessed by [Operator] as a non-material change to the work on track protection method resulting in training for the changes being carried out using toolbox talks for affected workers. The reporter’s seek confirmation that the removal of controls from this process, in the absence of alternative controls, does not meet the requirements for a material change.

The operator subsequently provided the following response:

Thank you for allowing time to discuss the concern raised by the reporting party. [Operator] would like to re-affirm that the current requirements include the Protection Office clearly communicating the worksite limits to the operators of track vehicles, and making an assessment to determine if visual delineation of the limits is required. [Operator] has since developed a Safety Notice, which clarifies the requirements for placing stop signs to delineate the limits of the work on track authority. This notice is also consistent with the reporting parties mentioned local procedure.

The Safety Notice mandates that “Where the TOA limits are not defined by facing signals (e.g. clear of a set of points) there is a risk that the track vehicles could foul the adjacent line or depart from the TOA limits without authority.  

[Safety Notice and diagram provided]

Regarding the reporting parties concern about vehicle operators often looking down and reversing during work; [Operator] already has documented processes in place to manage the risk of track vehicle movement and people and plant separation. These processes have not changed.

Regulator's response

REPCON supplied ONRSR with the de-identified report and a version of the operator’s response. The following is a version of the response that ONRSR provided:

ONRSR has received REPCON report number RR201900028 related to a reported concern regarding proposed changes to Track Occupancy Authorities.

ONRSR can confirm it has reviewed the information provided by the reporter and the response provided by the operator in both reports. On [date 3], ONRSR met with representatives of the operator involved to discuss the matter further and seek assurance that the operator was managing associated risks so far as is reasonably practicable. ONRSR is satisfied with the actions taken and response provided by the operator. The nature of the report will be considered in the planning of future regulatory activities as part of the ONRSR National Work Program.