Safety Issue
On the day of the commissioning, the engineer and technician had
been awake in excess of 14 and 12 hours respectively. The
commissioning works required sustained levels of concentration
which meant both men were probably suffering from some degree of
cognitive fatigue at the end of the day when they inadvertently
left the temporary wiring strap in situ. In the case of the signal
engineer, any such fatigue would have been compounded by disturbed
sleep and his anxiety as a result of a health scare the previous
day. Personnel performing safety critical signal work should be
fully cognisant of the risks associated with fatigue and any
factors which may predispose them to degraded work performance as a
result of fatigue. Planning safety critical work should also take
into account the risks associated with cognitive fatigue and
include measures to effectively mitigate such risks.
Safety Recommendation
The Australian Transport Safety Bureau recommends that WestNet
Rail take action to address this safety issue.