Change of metropolitan passenger service route [A] and route [B] [procedure]

The reporter states the change of procedure reverses the routes of both no. [a] and no. [b] [rolling stocks]. This change potentially increases the risk of rear end collisions such as those that have occurred previously at the [Location 1] platform.

Through the risk assessment (RA) processes (supplied to the ATSB and ONRSR) and review of previous incidents [Operator] identified no increase in risk for [rolling stock] to [rolling stock] collisions as a result of the change. This was further discussed during the RA sessions in which it could not be established how [Location 2] drivers being the second [rolling stock], would be more dangerous than [Location 3] drivers being the second [rolling stock]. 

Both depots share the [Location 4] / [Location 5] corridor and follow each other daily, stopping in [type] platform stops and in queues at traffic signals. (Photographic evidence supplied to the ATSB and ONRSR).

The additional control for the procedure that was carried over from the existing procedure is a 3 m stopping distance between [rolling stocks], 3 times greater than the 1 m requirement in [rules document] for the [Operator] network. 

Reviews of the investigations into the two minor [rolling stock] to [rolling stock] and one derailment that occurred during [procedure] - summary below, were spoken to in the RA sessions. Noting there were 200 [procedure] exchanges per week in the 5 years prior to [roster rotation] which is equal to 52,000 connections. This was also communicated in RA session 3. 

a) [Date] Derailment:

Driver did not position [rolling stock] at the required shunting marks or visually check the facing points. Following this the procedure was updated and a module was included in [program] 2022 for both [Location 3] and [Location 2] drivers.

b) [Date] Minor [rolling stock] to [rolling stock] (no damage):

Driver did not apply the correct braking techniques for [rolling stock] in a skid.

c) [Date] Minor [rolling stock] to [rolling stock] (no damage):

Possible over speed.

The reporter acknowledges Zoom meetings and have taken place and several Excel documents were revised. However, the operator has not provided a new work instruction, driver training or new documentation to drivers.

Three RA sessions were conducted. [Dates and times supplied to the ATSB and ONRSR]. RA including attendees and identified controls (also supplied).

[Operator] noted on [date] that drivers would not require training for this change and the change would be communicated through the usual notification processes embedded. These include the following, with evidence supplied to the ATSB and ONRSR:

• Presentations have been playing on a loop on the [information] screens in the depots since [date].
• Email evidence for depot.

Further to this [Operator] undertook the following:

The existing procedure was archived prior to [date] and new work instruction published – noting succinct comms to depot as distributed deemed a more effective communication of change (supplied to the ATSB and ONRSR).

• [Supervisory] drivers were at point for the first two nights to observe and support drivers – zero concerns raised and [Supervisory] driver presence has been considered as no longer required.

No issues have been raised by drivers to management teams at both depots since the change has gone live.

The reporter further states a safer plan has been written and presented to management. This plan outlines the known hazards of both routes with suggestions in order to mitigate some of the known hazards and minimise the collision risk. This plan appears to have been ignored.

The plan was emailed prior to the second RA session (supplied to the ATSB) held on [date]. Further to this, a review of ‘a safer plan’ was undertaken following this meeting and the plan was spoken to at the third RA session on [date].

Key points discussed included the following:

• As detailed in the document the ‘safer plan sequence’ cannot be followed step by step, or is out of order and mixes between business as usual (BAU) and exception occurrences.
  • The [Location 3] HSR challenged the plan in sessions 2 and 3 as two shunting moves are required.
  • The [Location 2] deputy HSR is adamant only one shunting move is required (this premise requires the inbound [a], the procedure and the outbound [a] to all be present simultaneously at the crossover which is improbable).

Below are the talking notes presented in the third RA session:

Having the citybound [rolling stock] first allows:

• immediate and tangible connection for passengers (protects and against weather)
• protection for drivers from aggressive passenger behaviour if told to get off at night but no connection visible 
• the single procedure [rolling stock] to wait for the outbound [rolling stock] to pass in the opposite direction 
• ensures there is only one shunting movement (reduces likelihood of [rolling stock] to [rolling stock] and derailment) 
  control for distance between [rolling stocks] is three metres plus.

 b)   Additional controls to be added:

• step down speed signage 30 km/h to be installed
• consider stopping place studs with procedure marking for second [rolling stock] position
• update onboard announcements from route [a] to route [b].

c)   Issue with ‘drafted safer plan’:

• multiple shunting requirements 
• multiple destination changes 
• passing passengers on reduced night time headway with 'Not In Service' a poor passenger outcome
• network standard is wait at the fouling line, not 30 m away
• opening door off level surface
• procedure has a timetabled return schedule and cannot move to [Location 6] or [Location 7] and [Location 8]   
• does not consider driver rest time at terminus
• new line markings will potentially add to confusion.

d) [Rolling stock] positioning tests were conducted at site on [date] to validate and address concerns raised in sessions.

Key outcomes:

• There is up to 6 m between [rolling stocks] available for safe passenger transfer on the level surface of the platform (photos supplied to the ATSB and ONRSR). The tape measure is the 3 m control.
• The highlighted control for additional studs was rejected as the platform tactiles are cited as reference flowing [rolling stock] tests.

Also supplied to the ATSB for further evidence is the consultation evidence for the procedure change that was undertaken.

The reporter is further concerned about the increased risk to staff and passengers with passengers transferring from one [rolling stock] to another at the same platform at the same time which is not done anywhere else in the system. The reporter further states it appears the change of procedure is financially motivated in lieu of safety considerations.

With regards to the last comment suggesting that this change was financially motivated in lieu of safety considerations, [Operator] response is as follows:

There is no financial incentive for [Operator] to operate the procedure one way or the other. The decision was purely made to improve accessibility on our network. Further to this, if anything the change is actually costing [Operator] more as [type A] km (which are increasing) are more expensive than [type B] km (which are reducing).

Overall [Operator] does not see an increased risk to either passengers or employees in changing the order of [rolling stocks]. Low floor [rolling stocks] to the CBD allow for a better passenger and accessibility outcome. The procedure has been an operational requirement since its introduction to [Operator] on [date].