Increase in incidents at [Location] yard

[Operator] acknowledges the reporter’s concerns and provides a response on each element below.

In summary, [Operator] is aware of the rail safety event trend in our [Location 1] Operations in [State] and has been taking action in response to incident trends for some time. When this trend was identified, [Operator] engaged with the Rail Infrastructure Manager (RIM), to conduct a review as our investigation activities identified two challenges: (1) potential rail infrastructure challenges and (2) route knowledge concerns.

[Operator] and [RIM] conducted a joint review, which included rail traffic crew from [Operator], as well as signal engineers and track maintainers from [RIM]. The purpose of the review was to unpack any current challenges on the infrastructure related to the grain operations in [State]. The review has resulted in a number of actions for both parties.

Outside of the review, [Operator] has also been working on improvement to its own operations, including the introduction of a new role – a ‘[Trainer]’ – being a person competent in a particular route, who is responsible for supporting rail traffic crew in route upskilling. Conversations are also being had with [Company], [Operator]'s customer, specifically relating to impacts of changing rosters and services.

Since the review, [Operator] has presented its improvement actions to the Office of the National Rail Safety Regulator (ONRSR) and continues to roll out preventative controls in conjunction with its interface parties, [RIM] and [Company]. [Operator]’s presentation to ONRSR is provided as an attachment to this response (supplied to the ATSB and ONRSR). These initiatives continue to be progressed.

In the five months post the review and the introduction of the Trainer, in addition to a two day stop for safety [date], [number] SPAD events have been reported, which is a 62% improvement on the five months prior to the activities.

The reporter states there have been a large number of SPADS in the past 10 months.

Whilst [Operator] acknowledges there has been a high volume of SPADs/authority exceedance events involving [Location 1] rail traffic crew, the reported number is incorrect. [Operator] has recorded [number] SPADs/authority exceedances since [date] specific to its [Location 1] Operations.

Following the three SPAD events in the month of [date], a stop for safety action was taken with the workforce over the course of two days. Incident data shows this activity, in addition to other changes, has had a significant impact in reducing occurrences, most notably the 62% reduction in SPADs. (SPAD graph provided to the ATSB and ONRSR).

As noted above, [Operator] has conducted a review with [RIM], in addition to investigations of each SPAD/authority exceedance event. Strategies have been developed to address route competency challenges as well as some key improvement opportunities with infrastructure design. ONRSR has requested and received investigation reports into [number] of these occurrences.

Multiple derailments due to track condition. The reporter advises track replacement works have since commenced with a blanket speed limit of 5 km/h in place throughout the yard.

Since [date], services managed by the [Location 1] depot have experienced four derailments due to track condition, two of these were in [Location 1] yard, which is managed by [Operator], and two were in sidings under the management and control of third parties.

[Operator] has a three-year capital expenditure plan, with approximately [amount] budgeted for works in [Location 1] yard in FY24, and [amount] in total across the three-year period. This plan is an extension of work which has been ongoing in [Location 1] yard. The 5 km/h speed restriction has been in place in [Location 1] yard since it was re-opened on [date].

[Operator] continues to work with third party siding owners/operators to improve track condition.

The reporter also states due to staff shortages, drivers are placed back on the roster the following day post a SPAD or safe work procedure breach.

[Operator]’s safety management system includes an approach focused on just and fair outcomes for our workers that may be involved, amongst other events, in a safety occurrence. [Operator]’s just and fair approach is predicated on promoting psychological safety for our people and encouraging an open, curious, and fair event learning process.

The just and fair process was, in part, enhanced based on feedback from our workers that the investigation process into safety events that resulted in being ‘stood down’ was not good for their mental health. The process has been enhanced with our leaders trained in its application – focused on understanding the event, the individual’s contribution to the event, and the behaviours exhibited by the person involved.

Through this deliberate approach to deepen our understanding of root cause, [Operator] has identified a number of improvements, such as improving lighting in yards, and engaging with [RIM] to enhance rail infrastructure (i.e., signals and signage). The approach enables [Operator] to focus on systemic change rather than blaming and performance managing the individuals involved.

For the [Location 1] operations, the [Local] Manager is responsible for making the determination in consultation with the [position] with three potential outcomes: (1) return to work, (2) duties reviewed, and (3) removed from duties. 

In relation to the reporter’s observations of perceived staff shortages, [Operator] continues to work with [Company] to manage the impact of train schedule variations and the flow-on impacts to crew resourcing.

Although being assessed for actual driving competency when being qualified, drivers are not being assessed physically on new lines.

[Operator]’s safety management system, specifically the [procedure] (supplied to the ATSB and ONRSR), details the minimum training and competency requirements for train crew. The [procedure] requires routes to be risk assessed to determine route complexity. Training requirements are then determined based on route complexity.

For:

• Non-complex routes, only a theory assessment is required to be completed to confer route competency. This assessment is marked by a route competent enterprise assessor.
• Complex routes, both a theory and a practical assessment (conducted by a route competent enterprise assessor) is required to be completed.

Through an action committed in the review activity on [date], [Operator] has reviewed route risk assessments to confirm assessed route complexities are appropriate. The review confirmed that the route complexity risk assessments are up-to-date and appropriate.

Some drivers are being signed off on lines with them simply filling out paperwork.

Please refer to response above.

Certain times, newly qualified drivers, are being used as [Trainer]s, when they have only recently been qualified themselves.

Section [number] of [Operator]’s [procedure] (supplied to the ATSB and ONRSR) does not require [Trainer]s to have additional qualifications, outside of being qualified train crew and route competent, to provide route tuition. Importantly, route tutors do not perform any training or assessment. [Trainer]s are qualified locomotive drivers with full route knowledge who have been trained to provide route tuition. The development of this standard was risk assessed in accordance with [Operator]’s safety management system requirements.

[Trainer]s provide route familiarisation and practical route tuition over a route, of which they hold current route competency. All route competency assessments are conducted by an enterprise assessor. 

Additionally, ONRSR has recently completed a compliance inspection in relation to driver route competency and training at the [Location 1] depot, on [date]. No findings were made in relation to the current processes for route tuition.

The reporter states there have been collisions resulting in damage to rolling stock as well as multiple derailments that have not been reported to the regulator. An example was provided of a collision at [Location 2] where a train was sent to be run around which was too long to fit safely within the track side clearance markers.

[Operator] is unaware of the event being referred to by the reporter. All incidents are reported into [Operator]’s event management system, out of which regulatory notifications are made by the central safety, health, and environment function. There have been no reports or evidence of rolling stock damage that do not correspond to a reported occurrence.

To prepare this response, we have discussed the event with local leaders and confirmed the local leadership team is not aware of an event at [Location 2].

[Operator] is aware of, and has reported to ONRSR, a collision event at [Location 3] on [date]. There has been no reported occurrence since.

Trains of excessive length are being sent out to sidings requiring multiple shunts as they can't be run around.

Train lengths are complaint to the RIM requirements and [Operator]’s safety management system.

The normal practice for the customer is to order maximum wagons for load points, which in locations like [multiple Locations] require multiple shunt movements. [Operator] continues to work with the customer [Company] to build efficiency into train plans to reduce the volume of shunting required.

Many loading sites do not provide for adequate walkways (many of which are non-existent or deteriorated and without lighting).

As the ATSB will appreciate, rail operations in this area occur on third party infrastructure, and as such, loading sites involve multiple stakeholders. Through [Operator]’s review referenced above, [Operator] has committed to working with these stakeholders in relation to loading sites to continually improve the adequacy of walkways and lighting. One recent example is the work undertaken by [RIM], [Company], and [Operator] in the [Location 3] siding extension works. [Operator] is also progressing works on the walkway at [Location 4] siding.

Additionally, [Operator] management will be reinforcing the need for rail traffic crew to report any issues they perceive with the adequacy of walkways and lighting at loading facilities, as there are currently very few reports in [Operator]’s safety system regarding this issue.

Drivers are pressured by management to haul excess wagons due to limited time in the schedule for shunting.

As noted above, train lengths are compliant to RIM and [Operator] safety management system requirements. Given the variability of the loading sites and the production of commodities such as grain, there will necessarily be times at which not all wagons in a consist will be loaded. As such, there are occasions where empty wagons are left on the rear of loaded consists to reduce the time required to shunt. These decisions are made in compliance to all relevant loading and train length requirements.

In many cases shunt plans are not being completed prior to shunt movements within the yard. Operational shunters are being pressured by coordinators not to waste time when the schedule is tight or running late. The reporter provided an example where an operating maintainer was chastised by a coordinator for wasting time because they completed a modified continuity prior to pushing a lengthy rake of wagons at the request of the driver, into a workshop area occupied by maintenance personnel.

[Operator] executes an assurance program to confirm controls to manage its critical risks are implemented effectively. One of the tools used by frontline leaders to determine whether procedural controls are implemented is an [assurance tool]. In the suite of [assurance tools] available to all leaders and workers in [Operator]’s safety management system, two require the completion of a shunt plan to be checked. 

The [Location 1] operation utilises the [assurance tools]. On review of completed [assurance tools], no systemic issues regarding shunt planning have been identified.

[Operator]’s [position] and the [Local] Manager are currently spending time with operational teams to discuss the perception of time pressure.

The reporter further states trains are operating en route with expired brake tests.

Rail traffic crew are responsible for ensuring the brake tests are current and valid prior to departure. [Operator] is aware of a number of instances where trains have been delayed to enable appropriate time to be allocated to the completion of brake tests. On this basis, [Operator] does not believe the reporter’s concerns are valid.