SBR’s fatigue-management processes were ineffective in identifying the fatigue impairment experienced by the driver leading up to, and at the time of the occurrence.
The ATSB is satisfied that the actions taken by SBR will adequately address this safety issue.
SBR conducted an internal investigation on this incident which identified fatigue impairment of the driver on the train due to ill health. Since that time, SBR has instructed all staff that should they be identified and medically “unfit” for rail safety work, they will not be allowed to self-assess and return to work, unless the medical certificate has expired, or the doctor provides a release. In all cases, staff MUST be declared “fit” for rail safety work.
