Safety issue

Safety issue description

The procedures in the ARTC CoP for the use and verification of a conditional proceed authority were ineffective in mitigating the risk to the effectiveness of that authority arising from human error.
Issue number RO-2012-011-SI-03
Issue owner Australian Rail Track Corporation
Transport function Network Operations
Date issue released 22/06/2015
Issue status justification

The ATSB is satisfied that the additional action taken by ARTC, and continued engagement between ARTC and ONRSR, will adequately address this safety issue.

Safety action

Action type Proactive action
Action number RO-2012-011-NSA-020
Organisation Australian Rail Track Corporation
Action date 22/06/2015
Action description

ARTC will be trialling the use of additional information provided on the Conditional Proceed Authority (CPA), which will reiterate the requirement of the current authority in effect. This additional wording will reinforce the requirements of the crossing information contained within the current authority.

 
ATSB response

At the time of this report release, the safety actions advised by ARTC had not yet been fully implemented. The ATSB is satisfied that the actions proposed by ARTC and the ONRSR will, when completed, adequately address this safety issue.
Action status Monitor

Organisation response

Date received 07/10/2015
Organisation ARTC
Response status Closed
Response text

Following the release of this safety issue, ARTC have:

  • Designed, installed, and commissioned a conventional remote controlled wayside signalling system between Tarcoola and Spencer Junction (Port Augusta). This resulted in the cessation of Manual Train Authority Working in the area of highest train density on the Port Augusta – Kalgoorlie rail corridor.
  • Made significant progress in the development and field-testing of the Advanced Train Management System (ATMS). When rolled out as the primary safe working system significant improvement in system safety and train operating efficiency will be achieved.

The ARTC and ONRSR are continuing actions to review current practice, and identify areas of possible improvement, subject to robust risk assessment and review prior to implementation.