| Safety issue description |
The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations. |
|---|---|
| Issue number | RO-2014-016-SI-01 |
| Issue owner | Metro Trains Melbourne |
| Transport function | Rail: Other |
| Issue status | Closed – Adequately addressed |
| Date issue released | 06/07/2016 |
| Issue status justification |
The ATSB accepts MTM's proposed safety actions on this safety recommendation. |
| Action type | Safety recommendation |
|---|---|
| Action number | RO-2014-016-SR-38 |
| Organisation | Metro Trains Melbourne |
| Action date | 06/07/2016 |
| Action description |
The ATSB recommends that Metro Trains Melbourne consider additional risk mitigation measures to maintain train separation where the safeworking system allows permissive working. |
| ATSB response |
The ATSB accepts MTM's proposed safety actions on this safety recommendation. |
| Action status | Closed - Action Taken |
| Date received | 02/11/2016 |
|---|---|
| Organisation | Metro Trains Melbourne |
| Response status | Released |
| Response text |
MTM Response to Recommendation RO-2014-016-SR-038 |
| Date received | 17/06/2021 |
|---|---|
| Organisation | MTM |
| Response status | Closed |
| Response text |
MTM advised in relation to the deployment of TPWS:
MTM advised in relation to the removal of dark territories:
This does pose a risk to the program as these vendors have s significant workload within the rail industry. This risk is under active management. |
| ATSB response |
The ATSB accepts MTM's proposed safety actions on this safety recommendation. |
| Action type | Proactive action |
|---|---|
| Organisation | Metro Trains Melbourne |
| Action date | 06/07/2016 |
| Action description |
MTM issued a Weekly Operational Notice on 28 July 2015 stating that the existing details contained in Section 3, Rule 1 of the Book of Operating Rules and Procedures 1994 are to be deleted and the attached details in Annex 6 incorporating an automated voicemail facility is inserted. The voicemail facility includes a recorded recitation of the Rule. Annex 6 requires train drivers to call a telephone number and record a message advising that they are at an automatic signal at Stop and will be proceeding past the signal in accordance with the requirements of Section 3 Rule 1 of the Book of Operating Rules and Procedures 1994. |
| ATSB response |
The ATSB accepts that the voicemail facility acts as a means of alerting train drivers to the operational rules governing permissive working. However, the ATSB is not satisfied that this process sufficiently mitigates the risk of a similar accident. Accordingly, the ATSB issues the following Safety Recommendation: |
| Action status | Released |