RailCorp prosecuted over track worker's death - SMH

 
  kypros1992 Locomotive Fireman

Location: Sydney

Railcorp is being prosecuted for the first time in its history by the state's transport safety watchdog, following the death of a track worker struck by a train at Kogarah.

Tamati Grant, 59, died attempting to scramble clear of a southbound train from Hurstville just after 1am on April 13, 2010.

The fatality was attributed to the failure of a RailCorp employee, an area controller, at the train operator's Sydenham signalling complex to alert Mr Grant's cleaning team of the impending arrival of the train.

The Independent Transport Safety Regulator has confirmed it is prosecuting RailCorp and the area controller for breaches of the Rail Safety Act, 2008.
 
It is unclear what charges will be levelled against RailCorp, the operator of Sydney's CityRail system, or the area controller, who no longer works for RailCorp.

A 2010 prosecution of the Australian Rail Track Corporation, which manages freight lines around the country, resulted in a $200,000 fine. Under the Act, individuals can face jail terms of up to two years.

The report into Mr Grant's death by the Office of Transport Safety Investigations outlines a series of errors and breaches of protocol.

A crucial error, according to the report, took place when the area controller at Sydenham told the leader of Mr Grant's cleaning team that signal blocks were on, which would have prevented any trains from passing through Kogarah while they were on the tracks.

The blocks were not on, and by the time the area controller realised his mistake, the train was almost to Kogarah. Mr Grant's co-workers escaped onto the adjacent tracks.

The Office of Transport Safety Investigations made 10 recommendations to RailCorp as a result of the death, and three to the contractor Mr Grant worked for, Swetha International.

In the months prior to the incident, the area controller had been on sick leave, being treated for "psychological conditions and drug rehabilitation", and had wanted to call in sick on April 12.

Separately, the transport safety regulator has started proceedings against the Australian Rail Track Corporation over the death of a track worker at Newbridge, near Bathurst, in May 2010.

The proceedings against RailCorp are listed for mention in the Industrial Court of NSW on December 13, while the proceedings against the area controller are listed for hearing before the Chief Industrial Magistrate between March 4 and 13.

RailCorp confirmed it had not been sued by the transport safety regulator before.


Read more: http://www.smh.com.au/nsw/railcorp-prosecuted-over-track-workers-death-20121129-2ahso.html#ixzz2Da6pop7c

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  fixitguy Chief Train Controller

Location: In Carriage 4 on a Tangara

Tamati Grant, 59, died attempting to scramble clear of a southbound train from Hurstville just after 1am on April 13, 2010.
"kypros1992"


southbound train form hurstville?

on another note. its good to see them proscute railcrop for what could of been a preventable death. they really need to pick up their work ethic and safety measures.




  Blackadder Chief Commissioner

Location: Not the ECRL
If the procedures are followed then there is no problem with Railcorp safety methods.
  Dungog Diesel Junior Train Controller

If the procedures are followed then there is no problem with Railcorp safety methods.
"Blackadder"


Yes exactly, and that was the problem in this case. The signaller didn't follow the procedures. The procedures themselves are extremely detailed and comprehensive.

Fixitguy, do you actually know anything about the Safeworking components that rail workers are trained in, or are you just making uninformed judgements? Go and sit through all the various Safeworking units, read all the network rules & procedures, read all the OSPs (operator specific procedures), pass the assessments, then come back and tell us again that Railcorp needs to "pick up their work ethic and safety measures".
  boxythingy Chief Commissioner

Location: Banned
Unless it was widespread and involved signallers, why is RailCorp being charged if it was a bad decision of the former employee?
  KRviator Moderator

Location: Up the front
Because it did involve the Signaller. Signaller catastrophically failed to follow the procedure. RailCorp is the employer of said Signaller. Ergo, RailCorp is responsible for the actions of said bloke.

That RailCorp allowed such a bloke to remain employed in such a capacity knowing his history is deeply troubling to me personally. While the interlocking will generally prevent collisions, abnormal situations involving the human element are generally when things go wrong and knowing my safety is in the hands of someone who was - apparently quite recently - being treated for a drug addicion is worrying.
  Sir Thomas Bent Minister for Railways

Location: Banned
boxythingy, did you bother to read the thread, or do you just lack basic comprehension skills?

While the signalman did not follow a basic safety procedure, there is also an onus on the employer - in this case RailCorp - to ensure that said safety procedures are followed.

It is alleged that RailCorp also neglected to do this, which is evident even on a basic read.





  boxythingy Chief Commissioner

Location: Banned
boxythingy, did you bother to read the thread, or do you just lack basic comprehension skills?

While the signalman did not follow a basic safety procedure, there is also an onus on the employer - in this case RailCorp - to ensure that said safety procedures are followed.

It is alleged that RailCorp also neglected to do this, which is evident even on a basic read.




"Sir Thomas Bent"

I just thought RailCorp couldn't possibly get any more worse than this (being sued). I was wrong. Very extremely disappointed, especially when they strongly emphasise about safety above anything and everything else http://www.railcorp.info/about_railcorp/safety I honesty thought RailCorp would be the last thing on the face of this planet to be sued because of this.
  Jahommed Chief Train Controller

Location: Sydney
boxythingy, did you bother to read the thread, or do you just lack basic comprehension skills?

While the signalman did not follow a basic safety procedure, there is also an onus on the employer - in this case RailCorp - to ensure that said safety procedures are followed.

It is alleged that RailCorp also neglected to do this, which is evident even on a basic read.




"Sir Thomas Bent"
I just thought RailCorp couldn't possibly get any more worse than this (being sued). I was wrong. Very extremely disappointed, especially when they strongly emphasise about safety above anything and everything else http://www.railcorp.info/about_railcorp/safety I honesty thought RailCorp would be the last thing on the face of this planet to be sued because of this.
"boxythingy"


Why? The heard can only move as fast as the slowest buffalo. You can push safety all you want: all it takes is one to bring down the pack.
  seb2351 Chief Commissioner

Location: Sydney

boxythingy, did you bother to read the thread, or do you just lack basic comprehension skills?

While the signalman did not follow a basic safety procedure, there is also an onus on the employer - in this case RailCorp - to ensure that said safety procedures are followed.

It is alleged that RailCorp also neglected to do this, which is evident even on a basic read.




"Sir Thomas Bent"
I just thought RailCorp couldn't possibly get any more worse than this (being sued). I was wrong. Very extremely disappointed, especially when they strongly emphasise about safety above anything and everything else http://www.railcorp.info/about_railcorp/safety I honesty thought RailCorp would be the last thing on the face of this planet to be sued because of this.
"boxythingy"


 

 


ShockedShocked
Boxythingy is critical of RailCorp. STOP THE PRESSES!!

Idea
 

Let's see. RailCorp provide the training, the policies, the procedures, the equipment, the safeworking systems, the staff and the oversight to prevent this kind of thing happen. The Regulator annually review RailCorp, and programs to increase safety standards are continually run for all staff and managers. Maybe that's why we don't have hourly safety breaches? 

 

But please, go on and paint all dedicated employees who get you around the network safely with the same brush. HOW ABOUT we put our brains into gear (I suggest you may want to invest in cobweb removal for yours) and go, hmmmmmmm clearly there were factors outside of RailCorp's control here?

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....

  TheLoadedDog The Ghost of George Stephenson

**sigh**  I'm so out of touch after my sabbatical.  So many new trolls and dribblers.  Why wasn't I told there was so much fun to be had?  I'd have come back sooner.

Nice to keep yer eye in, ya know?  8)
  sydnytrains Chief Commissioner

Location: McDonalds Front counter serving customers
Glad you've changed boxy. Glad you've changed!  Rolling Eyes

I'll be back soon, see if anything has changed.
  seb2351 Chief Commissioner

Location: Sydney

If the procedures are followed then there is no problem with Railcorp safety methods.
"Blackadder"
Yes exactly, and that was the problem in this case. The signaller didn't follow the procedures. The procedures themselves are extremely detailed and comprehensive.Fixitguy, do you actually know anything about the Safeworking components that rail workers are trained in, or are you just making uninformed judgements? Go and sit through all the various Safeworking units, read all the network rules & procedures, read all the OSPs (operator specific procedures), pass the assessments, then come back and tell us again that Railcorp needs to "pick up their work ethic and safety measures".
"Dungog Diesel"


"If the procedures are followed then there is no problem..."

Sure, but occasionally, and for umpteen different reasons, rules are broken. While some people say that rules are not written for rule-breakers, that is quite frankly not an acceptable position to take. The rules should include controls, checks and balances to mitigate against the consequences of inadvertent error, which can be reasonably expected to occur (by the railway's own risk assessments). It could be argued that the rules in question are lacking in that department. Seriously lacking.

"The procedures themselves are extremely detailed and comprehensive"

Yet the safety net they provide was unable to prevent the incident at Kogarah from happening. Perhaps the procedures are not so comprehensive, after all. More fluff, if you ask me.
"N959"


Point 1


"The procedures themselves are extremely detailed and comprehensive"

Yet the safety net they provide was unable to prevent the incident at Kogarah from happening. Perhaps the procedures are not so comprehensive, after all. More fluff, if you ask me.


Nothing wrong with procedures. Absolutely nothing. HAD the procedures been followed, then this incident would not have occurred. In fact, that was one of the findings (Page 57/58)

It was the failure of implementing the procedures, and the controls for those procedures that allowed this to occur.

Point 2


"If the procedures are followed then there is no problem..."

Sure, but occasionally, and for umpteen different reasons, rules are broken. While some people say that rules are not written for rule-breakers, that is quite frankly not an acceptable position to take. The rules should include controls, checks and balances to mitigate against the consequences of inadvertent error, which can be reasonably expected to occur (by the railway's own risk assessments). It could be argued that the rules in question are lacking in that department. Seriously lacking.


 



The rules did include controls, however those controls were not adopted. Controls such as double checking, warning lights, training, safety rules, audits, compliance checks were all in place, and by the risk management process, if followed would have prevented this from occurring.The controls used to prevent inadvertent error were not implement because they too are influenced by human favctors.

 HOWEVER, what would  do you suggest? Controls for the controls? End of the day, what has allowed this incident to occur namely was. 

*Not following the procedure and implementing the controls

*Gaps in knowledge. 

I would like to ask you, what controls besides those employed by RailCorp, as you have deemed them inadequate, would you have implemented? I can say now, short of 1 train allowed to move on the network at any time there is nothing more that can be done. This falls squarely down on the fact that human factors were to blame, and these human factors cannot be eradicated from any complex system. If the employees dont follow the rules, you can have the best system of controls in the world at your disposal be rendered meaningless. A culture of laxity does exist in regards to safeworking however in RailCorp. This is an underlying cause that through appropriate performance management, training and recruitment can be weeded out. 

 

  N959 Junior Train Controller



Point 1


Nothing wrong with procedures. Absolutely nothing. HAD the procedures been followed, then this incident would not have occurred. In fact, that was one of the findings (Page 57/58)

It was the failure of implementing the procedures, and the controls for those procedures that allowed this to occur.

"seb2351"


My point is that the body responsible for the safety system is supposed to protect against the consequences of errors that could be reasonably expected to occur, and that some of the errors associated with this incident were reasonably forseeable, not least because they already had occurred, just without the same catastrophic results. To say that "absolutely nothing" was wrong with the procedures more or less ignores the ALARP responsibility. Of course, what was reasonably practicable is not necessarily a matter for us to decide, at least not at an official level.

Addendum: it was reasonably practicable to take additional measures to mitigate the consequences of the errors that it was reasonable to expect would occur. Furthermore, the Protection Officer and private company involved could have, given suitable risk assessments, decided that a higher level of protection than the apparent minimum required under the Network Rules, was justified.
  seb2351 Chief Commissioner

Location: Sydney



HOWEVER, what would do you suggest? Controls for the controls? End of the day, what has allowed this incident to occur namely was.

I would like to ask you, what controls besides those employed by RailCorp, as you have deemed them inadequate, would you have implemented? I can say now, short of 1 train allowed to move on the network at any time there is nothing more that can be done. This falls squarely down on the fact that human factors were to blame, and these human factors cannot be eradicated from any complex system. If the employees dont follow the rules, you can have the best system of controls in the world at your disposal be rendered meaningless. A culture of laxity does exist in regards to safeworking however in RailCorp. This is an underlying cause that through appropriate performance management, training and recruitment can be weeded out.

 

"seb2351"




There are a number of things that could be done to mitigate the consequences of errors such as a train between the protecting signal and worksite being overlooked etc. What's more, they are fairly basic and some of them are already found elsewhere in the rule book; they just don't apply to this cheap and cheerful rule, the application of which was bound to end in tears from the day it was written.

(Apologies for editing my post while you posted your reply to it... I was tweaking the wording and didn't expect someone to reply so quickly at this time of night)




"N959"


Which makes the point the regulator (presumabley) is taking RailCorp to task over -the controls for mitigating this in were written elsewhere, but due to dare I say complacency, were not employed

The PO paperwork should have identified safe places in case a train does enter the worksite, the signaller should have noted down and cross checked the location of the CSB and train locations before issuing the authority. As you said, these provisions exist elsewhere in the rule book, which had they have been followed then we wouldn't be having this chat at this ungodly hour of the morning (The curse of the shift-worker!)

 

  seb2351 Chief Commissioner

Location: Sydney


Point 1


Nothing wrong with procedures. Absolutely nothing. HAD the procedures been followed, then this incident would not have occurred. In fact, that was one of the findings (Page 57/58)

It was the failure of implementing the procedures, and the controls for those procedures that allowed this to occur.

"seb2351"


My point is that the body responsible for the safety system is supposed to protect against the consequences of errors that could be reasonably expected to occur, and that it was reasonable to expect that some of the errors associated with this incident would occur, not least because they already had occurred, just without the same catastrophic results. To say that "absolutely nothing" was wrong with the procedures more or less ignores the ALARP responsibility. Of course, what was reasonably practicable is not necessarily a matter for us to decide, at least not at an official level.
"N959"


Lets look over it then. The procedure says a work on track authority is required,  because we are working on track- Admin control

Procedure says, due to the nature of the work, NAR is insufficent and that CSB will be required to give exclusive access to the track- Admin control/ Elimination control

PO protection plan states that safe areas be designated and easily accessible, as well as communicated to all staff- control existed and NOT implemented. This should have been picked up in the paperwork, but was seemingly ignored. The double check here has failed.(Training issue/complacency)

Now, to eliminate the trains we apply CSB. To prevent the signaller  from accidently setting a route, physical blocks are applied- Control implemented.

To prevent trains from being in the section between the signal at stop, and the worksite verbal confirmation that there is no train- Control as identified in the PO paperwork- ignored. As identified in the safeworking manual- ignored by the NCO. Thats ok, we have another barrier- train approach warning lights. Control not used and not identified in the paperwork. Double check has failed, and physical device is ignored.

Train approaches worksite- emergency broadcast feature (as a control)- Control not used. Lack of training or knowledge.

End of the day, what was being risk being controlled- getting hit by a train. A number of controls, and counter controls were employed and for the intial risk, if correctly used would have reduced the risk ALARP. The risk rating for the activity would have been reduced sufficently by the controls I listed above. However, lets allow for human factors, controls were still in place to reduce it to ALARP. That is the point I am trying to make, the system was safe. It was reasonable practical. HOWEVER, you cannot design a system that will be foolproof. If you allow your employees to be complacent and act as these people did on the night, then accidents will happen.


The issue here is not that procedures didn't work, its that the controls of enforcing the procedures were absent. Short of holding a gun to everyone's head, there is a limit on what can be done to enforce compliance. That is where the ALARP principle falls down, this was the 1 in millon incident that occurs even if you ALARP a risk.

  Sir Thomas Bent Minister for Railways

Location: Banned
G'day N959,

All them purty acronyms: could you explain to us what they mean?

Love and kisses,

Everyone else who isn't qualified in NSW safeworking.
  Highrise Assistant Commissioner


G'day N959, All them purty acronyms: could you explain to us what they mean?Love and kisses,Everyone else who isn't qualified in NSW safeworking.
"Sir Thomas Bent"


TWA - Track Work Authority

TOA - Track Occupancy Autority

LPA - Local Possession Authority

CSB - Controlled Signal Blocking (Now known as ASB - Absolute Signal Blocking.)

  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
G'day N959, All them purty acronyms: could you explain to us what they mean?Love and kisses,Everyone else who isn't qualified in NSW safeworking.
"Sir Thomas Bent"


Well said STB - thanks.

Is it a possible contributing factor to some accidents/incidents that those involved talk in acronyms/jargon rather than in reasonable  English?  Not everyone attributes the precise book definition to acronyms after a while.

Some Instructions are also written in acronyms where one needs a glossary at all times (a bit like N959's post) and it seems to me that the greater use of English may also form some level of reminder of the actions that need to be taken in a particular case?

I know that acronyms and jargon are very fashionable these days but I wonder if something a little more easily understood, albeit less fashionable, may have some advantages.
  N959 Junior Train Controller

The use of jargon, railway slang and casual, undisciplined language has been identified as a factor in incidents before, although regarding Kogarah, I don't think it was a key issue. Apologies for overindulging in jargon in my posts. I hope it doesn't shroud the general sentiment I was trying to convey in secrecy.
  Sir Thomas Bent Minister for Railways

Location: Banned
I just thought
"boxythingy"
Calling bulls**t on that one.
  Sir Thomas Bent Minister for Railways

Location: Banned
The use of jargon, railway slang and casual, undisciplined language has been identified as a factor in incidents before, although regarding Kogarah, I don't think it was a key issue.Apologies for overindulging in jargon in my posts. I hope it doesn't shroud the general sentiment I way trying to convey in secrecy.
"N959"
We know you weren't trying to be secretive. Yer one of the good'uns here whose posts are techinical and detailed.  



Just that I'm from Victoria.  I'm interested in this, from a work perspective. Betcha there's a few more like me.
I don't know what the difference between a CSB and ASB is. 

If you could though explain as you're going what a term means for us Mexicans, that'd be tops.
  Black1050 Chief Train Controller

Location: Out of the Metrop
...Is it a possible contributing factor to some accidents/incidents that those involved talk in acronyms/jargon rather than in reasonable English? Not everyone attributes the precise book definition to acronyms after a while.
"YM-Mundrabilla"


N959 correctly replied: "The use of jargon, railway slang and casual, undisciplined language has been identified as a factor in incidents before, although regarding Kogarah, I don't think it was a key issue. "

Further to that, I tend to disagree with some of the findings that identify "jargon" as a causal factor in incidents.  Slang and casual language that departs from correct protocol, particularly when communicating over the radio is certainly an issue, but as has been well identified in preceding posts, this was not the issue at hand which caused the tragedy.

Jargon is what it is - a specialized or technical language of a trade, profession.  It is prolific in other specialist fields, such as aviation, maritime, military and medicine.  The very same goes for acronyms.  They serve a purpose, and provided everyone involved knows what they are and understands their meaning, then it all works well.  They key is ensuring that all stakeholders involved, all share the same understanding.   When important changes are made EVERYONE must be made aware and educated in the new network rule/procedure changes.  Evidence suggests this doesn't always happen.It does NOT help when those with political or personal agendas change things that don't need to be changed, and change is implemented, but NOT throughout the whole industry/field. 
It seems, terms keep being changed, so that some office bound suit can say they've implemented changes they believe will improve safety.  A good example of this is, changing "Controlled Signal Blocking" to "Absolute Signal Blocking" as a knee jerk response to this Kogarah tragedy.  From the perspective of the workers using it's protection, there is little difference, for the Signallers and Train Controllers, there are some changes to their procedures to reduce the risk further (and fair enough too), but nothing that requires a complete name change, when older staff are only just getting out of the habit of using the term "CSB" instead "Stop and Block" which had been disused for years, and now trying to teach them a new name and definition for what is effectively the same thing.

There are many other examples of needless name changes where by the name change is supposed to increase safety.  
ie I was told they don't want me to use the term "Risk Assessment", but instead want me to use the term "Safety Assessment" because it sounds better and safer.  Seriously?  Idiots, and I wouldn't feed them. But their exploits are many, and continue to this day.

... 
Some Instructions are also written in acronyms where one needs a glossary at all times (a bit like N959's post) and it seems to me that the greater use of English may also form some level of reminder of the actions that need to be taken in a particular case?
"YM-Mundrabilla"


Where this is the case, then it is apparent that MORE and/or BETTER training is required to ensure those who need to follow those instructions do NOT need a glossary.  If simple bottom of the rung grunt soldiers or marines can work with many multiple acronyms in a wide range of operational circumstances, then surely some routine railway acronyms can be handled without much difficulty.

... 
I know that acronyms and jargon are very fashionable these days but I wonder if something a little more easily understood, albeit less fashionable, may have some advantages.
"YM-Mundrabilla"


I get the impression that acronyms and jargon are indeed fashionable in technological and electronic gadgetry fields, but elsewhere they have always been a normal part of the operational environment- ie aviation, military, medicine and even railway.  With railway, there has definitely been and increase in acronyms due to increased implementation of technology in the industry.  
At the end of the day, the purpose of using jargon, is to eliminate ambiguity and possibilities of misunderstandings that can result because plain english was used, and was open to interpretation, with the two parties involved having two different understandings.
It may sound confusing to someone who is not well versed in the terminology, but for those who work with it everyday, it is no big deal.


  Blackadder Chief Commissioner

Location: Not the ECRL
In terms of communication , it is a requirement that any communication be it face to face, via radio, etc is Clear,Concise,Correct and that the reciever of the information understands what is being said.
  seb2351 Chief Commissioner

Location: Sydney
I agree with your above thoughts, Signal blocking as a method of track protection is not adequate if it relies on the signaller visually checking for a train. Where is the cross check or record that they actually did this?

Maybe signal blocking should only be used within yard limits, or detonator protection ala TWA ( track work authority) when within a section be the new required minimum.

I'm on a phone ATM, but your earlier comments in reply to mine I also concur with and can see your point of view.

In regards to the acronyms, no where in the incident report was jargon referred to as being a cause of this incident. However, this agency does have a habit of over making acronyms ( OAM). I will try and make my posts less jargonly in the future.

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