Elements of the safety and environment management system not error tolerant
Date issue released
Safety Issue Description

Elements of the safety and environment management system are reliant on procedures being followed to manage safety risks. There is little scope for the system to recover when there has been a human error or other procedural error.

Issue number
Issue Status
Closed – Partially addressed
Transport Function
Rail: Operations control
Issue Owner
PerisherBlue Pty Ltd
Mode of Transport
Issue Status Justification

A broadcast radio call to make all operations staff aware of a red flagged train and its whereabouts provides another layer of control to strengthen existing controls. The requirement to confirm all controls are in place decreases the opportunity for a procedural error to occur. The Safeworking Check is a suitable method of monitoring compliance with procedures. The process for implementing independent verification of work when returning vehicles to service will be monitored.

Proactive action
Action number
PerisherBlue Pty Ltd
Action date
Action Status
Action description

Perisher has formalised a radio call in the red flag procedure to ensure that all operations staff are aware a train is being red flagged and its location. A further requirement for involved parties to confirm all controls are in place during the call decreases the opportunity for a procedural error to occur. The radio recordings provides an opportunity for review after the incident. 

This “Safeworking check” of procedures can be undertaken after the event with the recorded radio transmissions and the Duty Controllers Logbook examined. This can identify if the person involved is confirming that the controls are in place and that the duty controller acknowledges this prior to granting permission to enter the track area.

Perisher is reviewing the feasibility of implementing independent confirmation of the completeness of all the routine electrical and/or mechanical work needing to be verified as complete, in the return to service authority.

The completed changes and other major safety rules and processes were communicated to all staff who were required to demonstrate an understanding of the requirements prior to the 2020 operating season. Further consultation and communication will be undertaken with staff on other changes that are still in progress.