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?"
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.
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?"
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.
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?