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)Most of this has already been covered in detail in earlier posts, which you probably should read.
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
- 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 not just a simple case of negligence from the signaller or PO. RailCorp basically wore it but it wasn't all their fault either.
There were no significant changes to the CSB rule after the Kogarah incident. Repeating back protection details was already a requirement.
- more auditing of signallers compliance with rules and regulations.Supervision and auditing might help, but it doesn't address many of the real issues with the CSB/ASB rule.
- 24 hours a days supervision in Signalling Complexes.
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...
Remember, most signal boxes still have no supervision and never have had any.