RailCorp prosecuted over track worker's death - SMH

 
  Sir Thomas Bent Minister for Railways

Location: Banned
Just read that, and it seems a bit dodgy to begin with.  Taking out an ad-hoc request to close a line to me is dangerous: you may not know what is coming (adjacent signalboxes may not notify you of what is coming or what route it is coming from) and how heavy it is, and therefore what overlap is required.

In Victoria, we have people who clean the station pits and tracks of rubbish on a regular basis. 

This is done after the last train under an Absolute Occupation that is clearly timetabled, a circular is issued and NO trains are allowed between X signalling location and Y signalling location whatsoever, with sleeves being applied at what you'd call your Arrival Home (usually).  

Sleeves or blocking commands (when a computer-based interlocking system is used) are placed on, and documentation is handed to the person protecting the track.  You cannot so much as turn a wheel without their permission, nor reverse a signal.  The actual occupation is granted by the Train Controller in conjunction with the signalman.



People might deride the whole nanny-statishness of it, but you're playing with someone else's life here.  I'd rather have a track completely booked out and planned properly than having Joe Hairylegs rock up and ask me without knowing what else he or she has protected on other panels.

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  MD Chief Commissioner

Location: Canbera
Whats the point of fining Railcorp.
Its a Govt owned company that makes no profit and is totally reliant on Govt funding.
Ultimately, the Govt will have to pay the fine, and since the agency who is prosecuting Railcorp
is also a Govt dept, the Govt is effectively fining itself.
  Sir Thomas Bent Minister for Railways

Location: Banned
A lot of the theory is the same: what I'd call an Absolute Occupation and an 'S' or 'O' circular, you'd call a Local Possession Authority and Special Train Notice.  While we might have people working "under their own protection", or with a lookout, there was apparently an incident in inner Melbourne where someone working with that "under your own protection" rule was injured by a passing train.

When I first qualified in safeworking, after a very long examination by a senior Block and Signal Inspector, he said "Congratulations, Sir Thomas, you've now got a license to kill.  Remember that."  It's something that has stayed with me since - and it's why I reckon he told me.



I think also that we have sections that are completely automatic limits these track authorities.  While a lot of the inner areas of Melbourne are visible to the line controllers, they don't have any control of the signal aspects.

In fact, the closest we have down here is if a track not utilised in normal running (say a siding, or a platform road or track that is not used) can be booked out, but it will always be within station limits and I'd expect one of the people who is working on the track to come in and they physically see that the track is protected by sleeves on points and signals, sign the Train Register book, provide a phone number AND we let the line controller know.

However, I would not be comfortable with that being done on a main line unless I had a trackworker sitting next to me in the 'box.

It is a separate issue and one of two reasons why I don't believe in having massive centralised signalling locations.  The expedience in cost in my opinion significantly limits your ability to control one location properly, and you can't get a decent overview of what's going on.  Things like having trackworkers in any capacity in "your" location is diminished if you're worrying about all of the other trains.

Distraction is a big issue in my opinion with safeworking.  While you as the signalman should ensure you're not distracted, human nature can and will take over, and it is in my opinion beholden on the operator to ensure that you cannot be distracted, fatigued or in any other way impaired enough to not be able to ensure that anyone using the track in any way is safe.
Whether this is through managing workload, environmental factors such as excessive noise or poor ergonomics, and ensuring a drug- and alcohol-free workplace, then that is something which should have been enforced much more.

I remember reading this report and it was one of the two things that struck me (the first one being why they allowed trackworkers in an area that was confined in the first place without a planned occupation or Local Possession Authority) that RailCorp, on the basis of the evidence in the report, dropped the ball significantly by allowing an employee to work in a safety-critical role when it was known that he had impaired judgement.  I don't know RailCorp's culture, but in many places I have worked, often staff can feel obligated to their colleagues and to their immediate managers about not taking sick leave when they are not physically well enough to perform their role.

It is an interesting case, and while we are discussing the minutiae of it, I do have sympathy for the family of the rail worker and his co-workers and friends.  That is also more than worth noting.


-----------------------------------------------------------


Whats the point of fining Railcorp.
Its a Govt owned company that makes no profit and is totally reliant on Govt funding.
Ultimately, the Govt will have to pay the fine, and since the agency who is prosecuting Railcorp
is also a Govt dept, the Govt is effectively fining itself.
"MD"
Thanks for yet another in a long line of useless and cretinous posts you have made on this site.  Really.  What an awesome contribution.  Heck, it's like I've had my cat walk on the keyboard and pressed Send.




  heisdeadjim Chief Commissioner

Interesting from STB a couple posts up.

Being also Victorian qualified, I'd agree wholeheartedly with his point of view.

The reason why they're centralising thing is of course, cost. It's cheaper to have ONE MASSIVE SIGNALBOX but then as STB describes you have local issues that cannot be immediately addressed if there's not a local signalman.

I recall one set of gangers who jumped onto a track without letting me know and the train was facing a set departure signal. Driver had his brain on and rand me about the workers on the live track in front of him.

"WHAT workers?!". Crazy. They just decided they could do as they please, the lead worker once I made contact with him told me so in as many words. This is why decentralisation is bad - it fails to account for stupidity.
  S5_06 Station Master

There is one thing to sue RailCorp, its another for their guilt to be proved. The libel are have just put on this page, this publically accessible page, will be added to the file. Especially if RailCorp is found to be innocent....
"seb2351"



RailCorp are going to plead guilty. There are a few people in the firing line once they do plead guilty as well.
  seb2351 Chief Commissioner

Location: Sydney

There is one thing to sue RailCorp, its another for their guilt to be proved. The libel are have just put on this page, this publically accessible page, will be added to the file. Especially if RailCorp is found to be innocent....
"seb2351"



RailCorp are going to plead guilty. There are a few people in the firing line once they do plead guilty as well.
"S5_06"


 

Perhaps quote me in context in the future? 

  MILW Junior Train Controller

Location: Earth
The coverups continue.
Anyone looking for a safer railway where an accident like this could never happen again is going to be disappointed.
  TheLoneGunMan Assistant Commissioner

Location: At NF88.7 taking pictures
The coverups continue.
Anyone looking for a safer railway where an accident like this could never happen again is going to be disappointed.
MILW
Hi All,

Now I guess that this is your expert opinion? All who were apart of this incident will learn from the experience. I am NSW Safeworking Qualified, but my qualifications don't allow me to make a safeworking comment here, it's because I'm train crew not a Protection Officer or Worksite Supervisor.

TLGM
  MILW Junior Train Controller

Location: Earth
Hi All,

Now I guess that this is your expert opinion?
"TheLoneGunMan"


That would be correct.

Take it or leave it, it's a simple fact and quite obvious if you dig into the detail of what really happened. And that means going beyond the a*** covering OTSI report and actions of ITSR.

If it doesn't come out before, the truth will come out when the same thing happens again.
  HeadShunt Chief Train Controller

i think it more or less comes down to this:

The holes in the defences that allowed this incident to occur have not been plugged.

Why?
This is where we re-enter speculative territory, but it's probably not that hard to guess accurately.
Start with things like legal liability, politics, cost etc.
  Black1050 Chief Train Controller

Location: Out of the Metrop
Hi All,

Now I guess that this is your expert opinion? All who were apart of this incident will learn from the experience. I am NSW Safeworking Qualified, but my qualifications don't allow me to make a safeworking comment here, it's because I'm train crew not a Protection Officer or Worksite Supervisor.

TLGM
TheLoneGunMan
Hmmm... If you're a member of "crew" for the entity, surely you've seen cover ups before...  Whilst you may not be experienced first hand in worksite protection, perhaps you have seen the way the entity conducts investigations...  It is interesting how some investigations pan out.  If it looks like a pleb like crew are to be deemed at fault, the investigation progresses like a non stopping freight train and with the diplomacy and tact of a bull in a chinaware shop.  But if it seems the fault lies above the pleb level, and somewhere in the management echelons, then the investigation progresses slowly and quietly until it almost disappears and in some cases, no trace of it ever happening can be found...

Like you, I have no worksite protection experience, however I have seen how the entity works...  I see exactly where MILW (and HeadShunt) is coming from and am not surprised.
  HeadShunt Chief Train Controller

The best thing about this coverup for the railways, ITSR and OTSI is that it's not really a coverup - it's a case of hidden in plain sight. The holes in the defences are there for all to see, if only they know where to look. But most people will be looking elsewhere. Fantastic!

It is interesting how some investigations pan out. If it looks like a pleb like crew are to be deemed at fault, the investigation progresses like a non stopping freight train and with the diplomacy and tact of a bull in a chinaware shop. But if it seems the fault lies above the pleb level, and somewhere in the management echelons, then the investigation progresses slowly and quietly until it almost disappears and in some cases, no trace of it ever happening can be found...
Black1050
Glad I am not the only one who is not so naive as to believe that nothing of the sort could ever happen in our wonderful, just, transparent society, and with our great SAFETY FIRST culture. Anyone who has been around a decent length of time is likely to have run into the approach you describe. One thing about this case is that the next time someone gets killed the excuses and attribution of blame used this time may not work again, although that probably won't stop the circus from trying to run a similar case. The common denominator will be the holes in the safety defences that will seemingly not be plugged under any circumstances... along with, more likely than not, decent doses of poor training, poor planning and dodgy practices rooted in cost minimisation.

This sorry state of affairs would almost be laughable were it not a matter of past and possible future fatalities.

All who were apart of this incident will learn from the experience.
TheLoneGunMan
That would be great, except that one of them is no longer with us, another was sacked, and besides, they are not the only ones who are involved in worksite protection. Many different people are working on many different worksites, and the fact is that little has changed since this tragic event so I have my doubts that everyone has learnt from it.
  KRviator Moderator

Location: Up the front
RailCorp fined $150,000, takes blame for track death

Sydney's train operator has pleaded guilty in its first prosecution by the rail safety authority over a 2010 death in which a track cleaner was struck and killed by a train while he was working at Kogarah.
RailCorp has been fined $150,000 over the incident, which resulted in the death of Tamati Grant, 59, and highlighted numerous failures in RailCorp's safety procedures.
View the full story
As has been stated elsewhere, the holes in the defences that allowed this incident to occur have not been plugged.
The changes made will not prevent a repeat incident because they did not address the real problems, which were briefly touched on in OTSI's report but conveniently not mentioned in the case and do not appear in the newspaper article. In fact, some changes made since this tragic incident have increased the risk of a repeat.
"HeadShunt"
Does anyone else find it obscene that RailCorp gets fined $400,000 because some blind - but alive - bloke can't hear announcements, yet a RailCorp employee kills a bloke through his gross negligence and they're only fined $150,000?!?

What's wrong with this picture?
  s3_gunzel Not a gunzel developer

Location: Western Sydney, AU
Hello double-standards.
  HeadShunt Chief Train Controller

Does anyone else find it obscene that RailCorp gets fined $400,000 because some blind - but alive - bloke can't hear announcements, yet a RailCorp employee kills a bloke through his gross negligence and they're only fined $150,000?!?

What's wrong with this picture?
KRviator
I don't think it is fair to say that it was gross negligence on the part of a single employee. Among the many things not mentioned was the fact that there was a desperate effort to hang the signaller but in the end he was not found guilty of any offence.

There were serious problems at a number of levels involving several people/departments that in the end failed to prevent this incident from occurring. The laptop computer story is part of the picture, but has been used as the dancing monkey to grab everyone's attention while other issues are ignored. As I have already written, the changes made since the incident will not prevent a repeat, and some of the changes may even increase the risk of it happening again. The fact that these issues were not really borne out in the case combined with the difference in penalties you mentioned is a sign of how screwed up the legal system is.
  KRviator Moderator

Location: Up the front
I've got to disagree with you.

The signaller told the PO the blocks were on. They weren't. On the basis of that assurance, the gang went to work. It wasnt even a case if blocking the wrong line, or the wrong signal - which would be a regrettable but understandable mistake. He didn't have any blocking facilities applied when he told the PO he was safe to commence work. The signaller couldn't operate the MetroNet radio, yet alone in an emergency situation and didn't even know how to send an ALL TRAINS STOP message, arguably the one thing anyone who works in a box should know. It's easier to stop everything, sort the problem, then get things moving again than deal with a dead ganger. Instead he rings a CSA on the phone and asks a 3rd party to relay a safety-critical safeworking instruction.

There were several things that could have prevented this occurrence, but the single overriding issue was the signaller told a PPO he had protection applied when he didn't. Why? Who knows. Sending email. Watching a movie. I don't know, and frankly, I don't care. But I put my life in their hands every time I'm out of the cab, and to know one bloke screwed up this bad makes me wonder "are there any others like him?"

Then there is the legal system that has issued judgements against RailCorp. $150,000 for killing a bloke, or $400,000 for I audible announcements. Justice? Balance? I don't see either.
  HeadShunt Chief Train Controller

I've got to disagree with you.

The signaller told the PO the blocks were on. They weren't. On the basis of that assurance, the gang went to work. It wasnt even a case if blocking the wrong line, or the wrong signal - which would be a regrettable but understandable mistake. He didn't have any blocking facilities applied when he told the PO he was safe to commence work. The signaller couldn't operate the MetroNet radio, yet alone in an emergency situation and didn't even know how to send an ALL TRAINS STOP message, arguably the one thing anyone who works in a box should know. It's easier to stop everything, sort the problem, then get things moving again than deal with a dead ganger. Instead he rings a CSA on the phone and asks a 3rd party to relay a safety-critical safeworking instruction.

There were several things that could have prevented this occurrence, but the single overriding issue was the signaller told a PPO he had protection applied when he didn't. Why? Who knows. Sending email. Watching a movie. I don't know, and frankly, I don't care. But I put my life in their hands every time I'm out of the cab, and to know one bloke screwed up this bad makes me wonder "are there any others like him?"
KRviator


The signaller told the PO the blocks were on. They weren't. That's a serious error/act of recklessness. No disagreements there. BUT that sort of incident was a known risk that could easily have been guarded against.

Did the PO confirm by repeating back details of the protection as required? No. This double checking process was one of the only safeguards in the rule and it was not followed. There was not even any clear discussion of which signals were to be used. The PO was also clearly negligent.

What other safety measures were in place to protect the workers from approaching trains or signaller failure? Nothing aside from a lookout at the worksite. No red flags/lights, no detonators, nothing.

What was the lookout doing? Looking the wrong bloody way, in the opposite direction to that from which the train approached. That's poor form and it meant that the only secondary safety measure was more or less ineffective.

There were gaping holes in the safety defences that failed to guard against KNOWN hazards. There are many things that can distract or affect the focus of signallers, or otherwise impact on their performance, and using personal computers is only one of them. Heavy workload is another. Poor training is another. An adversarial workplace environment is another. Poor health is another. That's why the holes needed to be plugged, but they were not, and alarmingly they still aren't.
See what I am getting at?

When the train entered the worksite, what did the worker who was hit try to do? Climb up on the platform right in front of an approaching train. Incorrect response. Probably just poor training and therefore not his fault but it ultimately cost him his life. His response was the last line of defence.

During the pre work briefing, did the PO indicate that lying in the six foot was the appropriate emergency response if a train somehow approached? It doesn't sound like it. Things like that should have been part of the worksite protection planning, but it doesn't look like there was much in the way of planning at all.

And the problems don't end there for the PO and his employer.
The PO chose the CSB method but he knew that the safer TOA method was available.
Why didn't he use a TOA? It would have taken longer to implement. No excuse.

Protection Officers are the people primarily responsible for and each dedicated to the protection of single groups of workers on track, whereas Signallers are responsible for many things simultaneously including numerous trains and worksites. This PO chose a cheap and nasty method because it was quicker than the safer method, a move almost certainly supported if not expected by his employer and the cost/profit driven industry in general. He was sloppy with his communications and took the signaller's word as gospel without discussing the signals required, double checking or repeating back to confirm. Sorry, but that whole approach is not good enough.

Was the signaller fatigued at the time of the incident? Yes, probably. FAID score 87.

Was the signaller fit to be on duty at the time? Probably not. Apparently he felt like he had to return to work despite not really feeling up to it, or risk disciplinary action for poor attendance.

Did the railway know of the signaller's health issues? Yes

Did the railway know about the risks of the CSB method of protection? Yes

Was anyone on the inside surprised when the fatal CSB incident occurred? No. Most people thought it was only a matter of time.



the signaller told a PPO he had protection applied when he didn't. Why? Who knows. Sending email. Watching a movie. I don't know, and frankly, I don't care.
KRviator
Feel free to take the computer bait if you wish, but that's only one part of the story.
Everyone seems to think the case against the signaller is so damning, yet has anyone stopped to think why he isn't rotting in jail?

Aside from those directly involved on the night, blame for this incident is shared among several people in various offices of several different organisations, not just RailCorp and its predecessors.

It starts at the top with the people who wrote, assessed and approved a fragile rule, then allowed it to be overused and abused by money conscious Perway branch and infrastructure contractors, exposing front line workers to the consequences of that KNOWN fragility.

Infrastructure maintenance managers, especially with private contractors, are responsible for pressuring worksite protection staff into getting jobs done with fewer people and/or in less time in the name of saving money and/or increasing profit. This coupled with the unshakable on time running focus influences decisions relating to the choice of worksite protection method which directly impacts on the level of risk to which workers are exposed.

Training at all levels, including signallers and POs, and the people working on track who need to be given more rigorous training on how to deal with unexpected approaching trains rather than just assuming that the words "blocks on" mean that it won't happen. The fact is that worksite incursion does happen occasionally, especially with fragile rules.

Rail Safety Workers with mental health issues who have indicated that they may not be fit for work should be monitored very closely. Workers, especially long term committed workers (meaning most signallers, drivers and many other front line staff) should not feel that using leave entitlements, even for extended periods, could jeopardise their employment. This callous approach could lead to unfit employees coming to work when they should be off sick. Employers continue on this path of burning out and dumping workers like worn out equipment at their peril.

Fatigue issues still need to be addressed.

Personal computers and other distractions need to be eliminated from the operational environment.

And there are other issues. I've barely touched on the so far as is reasonably practicable risk management standard mandated under law and the problems with heavy reliance on administrative controls.

In the end, money has trumped safety yet again, this once in a decade incident will be written off as an acceptable cost of doing business; one contractor was killed and one of the erring workers was sacked. Neither the regulator nor the investigator appear to have much interest interest in exploring matters that were not mentioned in the latest newspaper article. The investigator made a few recommendations but they are not legally binding orders. There are parallels with the handling of "known safety issues" in the aviation industry.




I put my life in their hands every time I'm out of the cab, and to know one bloke screwed up this bad makes me wonder "are there any others like him?"
KRviator

If there are any other signallers like him, I can guarantee you that with CSB/ASB, the structure in place will do little to prevent their erroneous or reckless acts from causing disaster. Do you care about that?

Then there is the legal system that has issued judgements against RailCorp. $150,000 for killing a bloke, or $400,000 for I audible announcements. Justice? Balance? I don't see either.
KRviator

I totally understand this view and while it seems ridiculous at first, after reveiwing the report and the case http://www.caselaw.nsw.gov.au/action/PJUDG?jgmtid=164042 I had another thought that perhaps the lowish fine arose from the fact that one of the measures already implemented by RailCorp, in the form of increased supervision in signal boxes to eliminate personal computers etc is very expensive, probably costing millions per year, coupled with the fact that while ITSR was prosecuting RailCorp it also seemed to lay much of the blame with the signaller.* On the subject of increased supervision, not only is it an expensive measure but it may not even prevent a repeat incident because personal computers are not the only path to disaster.

*This is the same signaller who had already been found innocent of any offence for negligence during his own prosecution by ITSR, but it did not matter because the court case in question was ITSR vs RailCorp not ITSR vs the signaller - they could badmouth the sacked worker as much as they liked.

It must also be borne in mind that there may have been unpleasant ramifications for ITSR if too many stones had been turned, but who prosecutes the regulator?
  KRviator Moderator

Location: Up the front
There's no requirement for a lookout if you've got absolute occupancy of a portion of line. That's one of the reason's we use CSB when inspecting a train. One bloke on the engine, his mate walking back. You can't have eyes in the back of your head, and being your own lookout is fraught with danger - as the Signal Techs found at Singleton. Even with a lookout, if you don't act on his advice - as more Signal Techs did (or didn't) do at Strathfield - can only end in tears.

I take issue with the repeating back of signals too. While I see the intent of the rule, it is unreasonable to expect the driver of a freighter to know every signal number - or even their designation - they they may need blocked. Consider Blacktown, Strathfield or any number of other points on the network set up for terminating moves with several signals allowing access to almost every line. And let's not forget to include shunt signals as well, as they also need to be blocked. Am I expected to know every signal number?. According to the rules, yes.The rule as a whole is well-intentioned, but unworkable in practice unless it is in relatively simple double-line territory. The availability of the Drivers Route Knowledge Diagrams now is a big help, but their publication is a relatively recent decision. Ask many of the experienced freight drivers if theyve seen them and the answer is a blank stare... I had an old copy at first and I had to get it from a CityRail Guard here. PN didn't have anything like that, yet alone make it readily available to their crews, yet it is the single most useful thing I found - particularly on work trains...

As for why the Signaller didn't fall foul of the legal system, I would guess for the same reason Christian Scholl is still a free man, despite his negligence killing 11 people at Kerang. Or the Driver that killed 3 people at Benalla when K183 hit him... The legal system is broken, with lawyers squabbling over the meaning of "gross negligence" versus "ordinary negligence" as one applies to the charge and the other doesn't.

Through his actions - and inactions - the Signaller killed a bloke. He deserves to be punished for it, not get off because "the system" set him up to fail. If he worked to the rule book and someone died, fine, but this bloke didnt. I will extend this criticism to his PO as well, though he may be forgiven for believing he did have a legitimate protection system in place, even though it was not optimal, it would have sufficed for the job at hand.

I will certainly agree that more robust training is required at all levels to guard against untoward things happening, but also to mitigate the consequences when they do. Unfortunately, training costs money, and no one wants to pay for it.

So where does that leave us, both as operating crew, but as an industry as a whole? Surprised
  HeadShunt Chief Train Controller

It is important to note that CSB/ASB is not an absolute occupation. It is not even classified as a "work on track authority" under the RailCorp rules. It is a simple line blockage. When trains approach, protection can be temporarily removed to allow them to pass. The safer TOA method which I mentioned is a form of absolute possession or occupation. Protection for TOA includes red flags, detonators and more detailed implementation drills. Ideally possessions are advertised 7 days in advance on special train notices or other circulars, combined with cancellation of the train service for the area or programmed diversions (this is an LPA), whereas CSB can be requested without any notice or any programmed alterations to the timetable. Compare that to CSB/ASB and you'll find there is a big difference in terms of safety integrity, although for those not experienced in worksite protection the distinction may not be immediately apparent. Sir Thomas Bent also covered this in his posts.

It is also important to note that CSB/ASB for the protection of train crew who have to leave their cab is NOT the same as CSB/ASB for infrastructure maintenance worksites, and my focus is firmly on the latter. The circumstances under which the two versions of the rule are used differ, as do the protection requirements set down in the rule. Yes it is unreasonable for train crews to know the signal numbers, but in my experience it is not really expected of them. When it comes to infrastructure maintenance worksites, the POs are supposed to draw up comprehensive protection plans and give comprehensive pre work briefings; they need to know that every point of access to their worksite is protected and the signals and points being used for that purpose. The vast majority of CSB/ASBs issued are for infrastructure maintenance worksites; their use by train crew is far less common, thereby reducing the probability of disaster. I have not thought much about improving the situation for train crew using CSB, but there are things that could be done. In multiple line areas, perhaps stopping all trains on all adjacent lines while the driver is out of the cab would help, by compensating for the unplanned nature of the operation and for the fact that drivers are not as well practised in worksite protection as dedicated protection officers etc. That's just one suggestion. Of course it would not go down well with the on time running freaks.



Through his actions - and inactions - the Signaller killed a bloke. He deserves to be punished for it, not get off because "the system" set him up to fail. If he worked to the rule book and someone died, fine, but this bloke didnt. I will extend this criticism to his PO as well, though he may be forgiven for believing he did have a legitimate protection system in place, even though it was not optimal, it would have sufficed for the job at hand.
KRviator


Again, the actions of the Signaller were quite clearly the immediate cause of this tragic incident, but they are not the whole story, the rest of which deserves some serious attention.

The requirement to ensure, so far as is reasonably practicable, the safety of rail operations was set down in the then Rail Safety Act 2008. The SFAIRP obligation applies to individuals and corporations and means that people in charge of designing the safety net are supposed to include controls sufficient to guard against reasonably foreseeable events.

In my opinion, it was reasonable to foresee that, sooner or later, a signaller would authorise work under CSB to proceed with a train approaching the worksite, whether through pure recklessness or honest error. It has happened before, and such an event had obviously been foreseen because some other methods of worksite protection included controls to protect against it. The trouble is that exactly what is reasonable has to be tested in court, and that will only happen if the regulator decides to go down that path. Similar SFAIRP issues in the aviation industry have occasionally been pushed much harder, probably due to the huge loss of life associated with plane crashes. As an exmaple, in court following the crash of Aero Peru flight 603 it was argued that even though the actions of a cleaner were the immediate cause of the incident, Boeing should have foreseen the misuse of its product and taken all practicable measures to prevent that misuse from leading to disaster (although much to the frustration of the chief investigator, the cleaner was also blamed for the incident in a separate case and jailed). However, "only" one hapless worker was killed at Kogarah, apparently not enough to get serious results in court, just a load of hogwash about lack of supervision and auditing that clouded the key risk management issue. It is clear to me that due to a lack of risk controls the CSB rule was, to use a phrase of the ATSB, "fragile in the face of human error".

Was it reasonably practicable for the PO (and his employer) to arrange to use the safer TOA method of protection? Of course it was. It has been done. RailCorp made this safer method available but a method with a lower safety integrity was chosen instead because it was quicker. This sort of attitude fails the SFAIRP test in itself. Then, to make matters worse, the reduced safety measures were accompanied by slack communication in breach of the rule.

Regarding the importance of repeating back protection details to confirm, the importance of this was highlighted in ITSR's Rail Industry Safety Notice No. 30. That document was probably issued before the relevant parties had decided how to proceed with the prosecution of RailCorp. The reason why double checking is so important is that unlike the TOA or other proper possession methods, there is little else in the way of safeguards provided under the CSB method. The relative fragility of the rule is also well illustrated by using the Reason Swiss cheese model.


So where does that leave us, both as operating crew, but as an industry as a whole?
KRviator
It leaves you and every other worker on track potentially exposed to risks unnecessarily.

The focus now should be on taking all practicable measures to reduce the risk of future worksite incursions, and simply blaming the signaller because he had a computer and considering the case closed on that basis ignores the fact that a worksite incursion could also have happened if he was otherwise distracted, overloaded, fatigued or otherwise not fit for duty (and the last two did apply to him). Furthermore, failure of the PO to correctly identify his worksite location is another risk that could lead to worksite incursion because there is little in the way of controls that could stop it. Has it happened? Yes, but luckily not with fatal consequences.
  Braddo Deputy Commissioner

Location: Narre Warren
$150,000 fine for loss of life is nothing but an insult to the family involved. It's sad that something as simple as a detonator could have prevented this unfortunate incident.
  HeadShunt Chief Train Controller

It's sad that something as simple as a detonator could have prevented this unfortunate incident.
Braddo

That's a simple salient fact.

Flags/lights and dets would have made a HUGE difference, irrespective of supervision. They can protect against far more than personal computers in the signal box.

By contrast, I think the argument that increasing supervision and auditing in signal boxes would prevent trains from being sent into worksites is much weaker. Supervisors cannot oversee every single operation in a large signal box like Sydenham, nor are they necessarily equipped with the knowledge or experience to understand what is going on, let alone intervene. They are just another huge expense to a railway already deeply in the red.
  Raichase Captain Rant!

Location: Sydney, NSW
I understand a lot of the work at Glenfield Junction is being done with red flags, controlled signals at stop and three detonators on the rail.
  Black1050 Chief Train Controller

Location: Out of the Metrop
See both Headshunt's and KRviator's points of view and somewhat agree with both.


"The signaller told the PO the blocks were on. They weren't. On the basis of that assurance, the gang went to work. It wasnt even a case if blocking the wrong line, or the wrong signal - which would be a regrettable but understandable mistake. He didn't have any blocking facilities applied when he told the PO he was safe to commence work. The signaller couldn't operate the MetroNet radio, yet alone in an emergency situation and didn't even know how to send an ALL TRAINS STOP message, arguably the one thing anyone who works in a box should know. It's easier to stop everything, sort the problem, then get things moving again than deal with a dead ganger. Instead he rings a CSA on the phone and asks a 3rd party to relay a safety-critical safeworking instruction." - KRviator

- Yep the signaller stuffed up.  Stuffed up BIG TIME.
It does for me however, ask the BIG and Important question of:
What on earth was he doing in there on duty?  Especially in such a safety critical role.
If another signaller was on duty that night, would those events have unfolded the same? We cannot guarantee that the unfortunate cleaner would still be alive, but the chances are much higher that he would be, particularly a signaller who was in a good mindspace, and was both competent and confident at both working the panel itself and metronet radio.


"Through his actions - and inactions - the Signaller killed a bloke. He deserves to be punished for it, not get off because "the system" set him up to fail. If he worked to the rule book and someone died, fine, but this bloke didnt. I will extend this criticism to his PO as well, though he may be forgiven for believing he did have a legitimate protection system in place, even though it was not optimal, it would have sufficed for the job at hand." - KRviator

- Agreed, he is responsible for the death.  However don't believe he bears 100% responsibility.  The system shouldn't have allowed him to even be at work.  I feel that is different to "the system set him up to fail".  My position is he shouldn't have even been allowed to be put in a position where he had such responsibility whilst he was not 100% ready for duty.  If that means he's taken off safeworking duties temporarily, so be it.
I would point responsibility to the Signaller, his employer and the PO.


"There were several things that could have prevented this occurrence, but the single overriding issue was the signaller told a PPO he had protection applied when he didn't." - KRviator

- Railcorp Train Crew are usually taught when obtaining CSB/ASB, after they have been given the assurances that the relevant signals are at stop and blocking facilities are applied, to then ask/verify - "Are there any trains in the section?" or along the lines of - "Are all trains clear of the section?".  Even if the signaller has stated all trains are clear of the section.  Human factors perspective, it gets (it should) the signaller to check again, double check if you will - theoretically another layer of protection.


"Did the PO confirm by repeating back details of the protection as required? No. This double checking process was one of the only safeguards in the rule and it was not followed. There was not even any clear discussion of which signals were to be used. The PO was also clearly negligent" - Headshunt

"I take issue with the repeating back of signals too. While I see the intent of the rule, it is unreasonable to expect the driver of a freighter to know every signal number - or even their designation - they they may need blocked... "  - KRviator

- My thoughts are the idea of the readback, isn't necessarily with the idea in mind that the driver knows each of the signal designations in the area or exactly where each of the signals are.  By reading back the signal designations of the signals being used for blocking, it can also help reiterate to the signaller which signals are being blocked - if the driver reads back the signals the signaller stated, and they are the incorrect signals, hopefully the signaller will recognisse this and correct it.  From a human factors perspective it is an additional line of defence.


"Protection Officers are the people primarily responsible for and each dedicated to the protection of single groups of workers on track, whereas Signallers are responsible for many things simultaneously including numerous trains and worksites. This PO chose a cheap and nasty method because it was quicker than the safer method, a move almost certainly supported if not expected by his employer and the cost/profit driven industry in general. He was sloppy with his communications and took the signaller's word as gospel without discussing the signals required, double checking or repeating back to confirm. Sorry, but that whole approach is not good enough."
- Heashunt
- +1 110% in agreement.


"Rail Safety Workers with mental health issues who have indicated that they may not be fit for work should be monitored very closely. Workers, especially long term committed workers (meaning most signallers, drivers and many other front line staff) should not feel that using leave entitlements, even for extended periods, could jeopardise their employment. This callous approach could lead to unfit employees coming to work when they should be off sick. Employers continue on this path of burning out and dumping workers like worn out equipment at their peril." - Headshunt

- Yep.  That really tends to depend on the draw as to whether you have a good line manager who will look after you, or will be more focused on making his performances statistics look good.  I've seen some really great effort and work of managers to support staff going through personal crisies, but also seen others that made the automatic coupler look more caring and sympathetic.  No consistency.  Like a driver who witnessed the decapitation due to a fatality, the driver continued their run until being overwhelmed from what they witnessed, and relinquished the remainder of shift.  Said driver recieved a phone call within the hour from their depot manager asking if they were good to work tomorrow.  Some quality managers there...


"I put my life in their hands every time I'm out of the cab, and to know one bloke screwed up this bad makes me wonder "are there any others like him?" - KRviator

"If there are any other signallers like him, I can guarantee you that with CSB/ASB, the structure in place will do little to prevent their erroneous or reckless acts from causing disaster. Do you care about that?" - Headshunt

- As a frontline worker on the recieving end, you can only do so much.  You use all the tools available to you to make the situation safe, but it's like  walking across a pedestrian crossing.  You can walk across in blind trust, or you can take a moment of caution to check both ways just in case, to make sure someone hasn't ignored the crossing or traffic lights.


"In the end, money has trumped safety yet again, ... " - Headshunt
- Hmmm, situation normal at the entity huh?  A sad fact of life really.  It shouldn't be.
  HeadShunt Chief Train Controller

- Yep the signaller stuffed up.  Stuffed up BIG TIME.
It does for me however, ask the BIG and Important question of:
What on earth was he doing in there on duty?  Especially in such a safety critical role.
If another signaller was on duty that night, would those events have unfolded the same? We cannot guarantee that the unfortunate cleaner would still be alive, but the chances are much higher that he would be, particularly a signaller who was in a good mindspace, and was both competent and confident at both working the panel itself and metronet radio.
Black1050
I agree, in short.


- Railcorp Train Crew are usually taught when obtaining CSB/ASB, after they have been given the assurances that the relevant signals are at stop and blocking facilities are applied, to then ask/verify - "Are there any trains in the section?" or along the lines of - "Are all trains clear of the section?".  Even if the signaller has stated all trains are clear of the section.  Human factors perspective, it gets (it should) the signaller to check again, double check if you will - theoretically another layer of protection.

- My thoughts are the idea of the readback, isn't necessarily with the idea in mind that the driver knows each of the signal designations in the area or exactly where each of the signals are.  By reading back the signal designations of the signals being used for blocking, it can also help reiterate to the signaller which signals are being blocked - if the driver reads back the signals the signaller stated, and they are the incorrect signals, hopefully the signaller will recognisse this and correct it.  From a human factors perspective it is an additional line of defence.
Black1050

Absolutely, the read back process gives the Signaller another opportunity to check his equipment and notice something that he may have previously overlooked. Due to the lack of protective measures in the rule, it could be the difference between life and death.

In fact, the Protection Officer should be listening for a fairly standardised set of words from the Signaller that provide the assurances set down in the rule, and he should also be using much the same language when he reads back. It's like a cockpit drill.

CSB/ASB must not be treated as issued until the assurance and read back process is complete.

The PO must not allow his gang to commence work in the danger zone before the process has been run through, and if he does, he is not only in breach of the rule: he's putting lives at risk, because there are often no other safeguards. This, IIRC, is what ITSR covered in their RISN no. 30.

If the Signaller merely says "righto mate, blocks are on" or otherwise does not offer the assurances in full, the PO should insist that he provide them. No assumptions, no "she'll be right, mate", no leaving it up to the Signaller to get everything right without his help. That is the Protection Officer's responsibility. He chose the CSB/ASB method and for the sake of the lives of his crew he had to ensure it was applied correctly and in full. Similarly, Signallers are obliged to challenge POs when they request inadequate or improper protection arrangements.

But what happened at Kogarah?

The PO said, "any chance of getting one?" presumably meaning platform one at Kogarah Station. The Signaller said, "righto mate, blocks are on" and gave no proper assurances whatsoever. The PO did not request specific signals that he wanted to be used, nor did he show any interest in which signals the Signaller had supposedly blocked, nor in the assurances the Signaller was supposed to give. The PO could not read back details that he failed to obtain from the Signaller, and the Signaller failed to ask the PO to read back details that he failed to provide him in the first place. Epic fail. That whole process took seventeen seconds, barely enough for the Signaller to apply the blocks on ATRICS, let alone complete the entire assurance and read back drill. "Righto mate, blocks are on" was not enough information for the PO to safely enter the danger zone. Assuming the PO really had completed the worksite protection plan before entering the danger zone rather than hastily scribbling it down after the fatal incident to make everything look right, why would he not mention the signals he supposedly nominated to the Signaller? Well, apparently the Signaller sounded like he was in a rush, and he assumed that there were no more trains for the night blaa blaa blaa. There's not much point having a plan if it is not used.

Safeworking is a shared responsibility
It is not my intention to excuse the behaviour of the Signaller, but he has already had his turn in the dock, and with the majority of people apparently heaping blame onto him, the importance of points relating to the actions of the PO cannot be overemphasised. Otherwise, if the Signaller is to be held overwhelmingly responsible, we might as well eliminate Protection Officers for CSB and give Signallers full responsibility for protection. Safe working is a team effort, and it always amazes me that when the smeg hits the fan shared safety responsibilities conveniently become the responsibilities of single people - the people easiest to blame for whatever reason, which in this case was the Signaller. That's not how it is supposed to work. The fact is that neither the Signaller nor the PO did their jobs correctly, and that is a massive oversimplification of the full story, other parts of which have been covered in previous posts.



How to make the situation safer
Many things could be done, including (as examples only):
(a) correctly follow the rule, particularly in terms of assurances and reading back, because these parts of the rule seem to have been flouted with alarming frequency by people who were never trained to appreciate their importance;
(b) limit the use of ASB, e.g. for station staff fetching lost property, crew inspecting trains and departmental level crossings etc, impose more safety control requirements for other activities
(c) modify the rule to strengthen safety controls, particularly for infrastructure maintenance e.g. restrictions in automatic signalling areas, red flags/detonators (with or without handsignallers), track circuit actuating clips, signal post replacement switches (an old idea from the UK, takes control of signals away from the Signaller, virtually fail safe way of ensuring protecting signals are red)
(d) higher forms of protection such as TOA should be used wherever possible; possessions take longer to implement but their higher safety integrity is worth the effort
(e) a "you have blocked a signal before an occupied track circuit" warning to remind signallers, as suggested in 2.50 of the OTSI report

The trouble with the above suggestions is that many of them will either cost time, money or both, and few stakeholders have much interest in solutions like that.


"In the end, money has trumped safety yet again, ... " - Headshunt
- Hmmm, situation normal at the entity huh?  A sad fact of life really.  It shouldn't be.
Black1050
I should qualify that by saying that money has definitely won at an industry level, but not at RailCorp because the increased supervision in major signal boxes is costing an absolute fortune for very little in return. It's a mess.
  Mall Rat Beginner

I've not read all of the comments on this thread, but from the parts I have read I will say. (it has been a long time since I read the report too)

Yeah the blocks weren't on when the Signaller said they where to the PO, but they were on seconds later... The real issue is that a train was already in the section, the signaller had not carefully checked that.

The Signaller was negligent, and so was the PO to some degree as well. Not asking for things to be repeated, not asking for assurances.

RailCorp has accepted responsibility, and instituted a few changes

- more auditing of signallers compliance with rules and regulations.
- 24 hours a days supervision in Signalling Complexes.
- I may be wrong, but I think the CSB/ASB procedure was changed that along with asking if the blocks are on and reapeating back the signal/points numbers - the PO must ask if the section is clear or rail traffic. A prompt to remind the signaller to check.

It's pretty surprising that such a safety critical workplace(s), did not have 24 hour supervision and support. I wonder what other workplaces in industries like rail and transport do not...

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