Queensland Rail did not have an effective process in place to ensure that safety-critical actions were coordinated and completed when multiple network control officers were involved in responding to an overhead line equipment emergency.
The ATSB acknowledges the significant action by Queensland Rail to provide greater assurance that the NCO Incident and Emergency Response Tool (MD-17-482) will be used by network control officers (NCOs) during an emergency response, and that relevant aspects will be considered during such a response, and that these actions will reduce the risk associated with this safety issue. As already noted in the ATSB report, emergencies can take many forms and procedures need to have some flexibility regarding the specific roles of each position in a specific emergency. However, the ATSB also notes that there is still limited guidance in the relevant procedures associated with how multiple NCOs and related personnel will coordinate their activities during an emergency response.
In July 2020, in response to the draft ATSB report, Queensland Rail (QR) advised:
Post this incident occurring, Queensland Rail has re-enforced the understanding of the contents of the mandatory checklist MD-17-486 [OHLE Incident – DOOC and TCL incident and emergency tool] with key Network Control employees and has scheduled an assurance activity for Quarter 2 of the 20/21 financial year to verify improvements and effectiveness in relation to use of this checklist…
Following further discussion with the ATSB, QR advised in August 2020:
Queensland Rail took the decision to make the NCO [network control officer] emergency checklist [MD-17-482 (NCO incident and emergency response tool)] mandatory for Category A and Prescribed Incidents after reviewing ATSB feedback provided in July 2020. The NCO checklist is currently undergoing consultation and review for resultant incident categories, currency and workload. Once this review is completed, the Rail Emergency Response Module will be updated and issued. The updated information will be cascaded to relevant parties via email and prestart briefs. The DOOC/TCL [day of operations coordinator / train control leader] will be responsible for ensuring MD-17-482 is completed, which is linked to the Rail Emergency Response Module.
In addition, in relation to controller training, QR advised:
In light of this particular incident Queensland Rail has subsequently developed “RMC Training: TT-04 Identifying Emergency Situations, OHLE”. This training material is designed to increase the ability of Network Control to respond to emergency situations where initial information is unclear and to heighten individual understanding of risks relating to OHLE, in particular re-enforcing the need to establish a 3m exclusion zone where an incident results in OHLE equipment being within 300mm of rollingstock until the OHLE has been de-energised, isolated and earthed. This training was conducted in July 2020.
The ATSB acknowledges the activities by Queensland Rail (QR) to address this safety issue. Although the activities to date have not specifically provided clearer descriptions of the roles of the various network control personnel in an emergency, the ATSB notes that QR is undertaking further work to revise its NCO checklist and Rail Emergency Response Module, and the ATSB will seek updates on the progress of QR’s additional work to address this issue.
In April 2021, Queensland Rail (QR) provided updated documents and information regarding its safety action to address this safety issue.
With regard to the NCO Incident and Emergency Response Tool (MD-17-482), QR finalised version 2.0 of the checklist on 11 September 2020. The revised version:
QR also advised that all key stakeholders were notified of the need to complete the form for category A notifiable incidents and prescribed incidents.
QR advised that in April 2021 it conducted a review of a sample of incidents that required the checklist to be completed. Of the 7 checklists sampled, the audit team found minor inconsistencies but noted overall that the rail management centre (RMC) was able to demonstrate compliance with the requirements in relation to the checklist. The audit also noted there was no space on the form for the NCO who completed the form to enter their name.
QR also provided an updated copy of MD-11-30 (Rail Emergency Response Module EP1-01), dated 12 August 2000. This updated procedure included clarification regarding the roles and responsibilities of a chief warden at an incident site. There were no changes to the roles and responsibilities of the NCOs or RMC personnel. However, it is noted that MD-11-30 already stated that:
As previously noted, QR advised that the day of operations coordinator (DOOC) / train control leader was responsible for ensuring the MD-17-482 checklist was completed.
