Concern regarding safety reporting culture
The reporter has expressed a concern relating to [Operator's] safety reporting culture.
The reporter states that multiple safeworking breaches and two separate wrong way running events have been appropriately reported through the [Operator's] internal reporting system; however, the reporter states that the operator did not report the breaches to ONRSR, nor do they believe that [Operator] conducted any safety investigation into the breaches. If any safety investigation was conducted, any findings from the investigation have not been shared with the workforce.
The reporter is concerned that there is a culture of non-reporting developing among workers, due to no safety action being taken or feedback provided on incidents that are being reported. The reporter states that those employees reporting and raising safety concerns are seen among their peers as troublemakers, rather than being encouraged for reporting concerns.
The reporter queries the operator's process for safety related reports.
We believe the two events in question are [reference numbers], both of which were reported in [Operator's] internal reporting system.
Event 1:
Two drivers swapped from their respective upline and downline vehicles in order to manage services and driver schedules. One driver completed the swap, one driver however changed ends of their existing vehicle and a made a small movement approximately 25 m in the vehicle. There was no conflict and no signals were passed.
A full investigation was undertaken to establish what had occurred; including reinforcing face-to-face vehicle handovers, and reminders about radio calls of vehicle numbers that you are in. These were shared with the driver group.
The event is ONRSR Cat C and will be reported as part of our annual submission as required.
Event 2:
Reported as a wrong way movement however was not. The driver was requested to change from the downline to the upline to complete a transfer to regulate services. The driver however proceeded past the manual selection box where they were requested to stop. The driver then proceeded out of service to the terminus for the turn around transfer. No signal was passed, no conflict or risk, therefore this will not be reported to ONRSR.
However, the incident was investigated, and an internal performance and retraining meeting was done with the driver in question to ensure they are aware of their selection boxes and transfer procedures.
In the year of 2022, [Operator] completed over 45 reports on Level 1 and 163 on Level 2/3 to ONRSR including the reporting requirements change from 1st of July 2022. Drivers and staff are supported to report any incident that gets recorded in our Event Management System (EMS).
On a daily basis at 12:00 p.m. all of these events are reviewed by the operations, safety, assets and maintenance teams. The ONRSR reporting category for applicable events is discussed at that meeting. It is understood that there was some confusion in the 12pm daily meeting when both of these events were discussed due to the change in ONRSR reporting and that these were not immediately notifiable to the Regulator. It is possible that because of the annual Cat C reporting happening at the end of the year, personnel could have been misinformed that these were not being reported to ONRSR at all.
Post-incident lessons learnt are shared with applicable groups. If it is a one driver incident, one driver will be spoken with (learnings shared wider if applicable). If it is a broader issue then the workgroup will be informed through safety notices, rail safety reminders or through any number of communications methods from Apps to notice boards.
As stated previously, over 100 hazards were reported last year and more through our EMS. Therefore, we believe that the reporting and follow-up culture is strong and robust where every individual incident / hazard is reviewed on its merits.
Further to the above, in September 2022, [Operator] engaged [Contractor] to undertake a safety culture survey. Results in relation to incident reporting across the board were provided to the ATSB and ONRSR.
ONRSR has reviewed the reporter’s concerns and the operator’s response. ONRSR has liaised with the operator, has been provided additional information and is satisfied with the operator’s response.