There were non-compliances to the repeat back provision because it was viewed as onerous under certain Local Possession Authorities (LPAs). An opportunity exists to review rule non-conformance with the implementation of LPAs.
Sydney Trains undertook several measures to address this safety issue. These included targeted assurance activity of safety critical communications, identifying areas of improvement and providing feedback to staff. They also initiated a project to review existing standards, rules and procedures relating to safety critical communications and improve training and coaching of signallers and train controllers. A key focus of this training will be for signallers and train controllers to prompt and lead the read back process. The Australian Transport Safety Bureau has recognised the assessed level of risk associated with this safety issue, based upon Sydney Trains' advice of action against the safety issue. The Australian Transport Safety Bureau is satisfied that the action taken by Sydney Trains has adequately addressed the safety issue.
The Australian Transport Safety Bureau recommends that Sydney Trains undertake further work to address this safety issue.
Sydney Trains have advised of their acceptance of recommendation RO-2013-017-SR055 and advised of their intention to undertake targeted assurance activities to determine whether non adherence to safety communications protocols during the implementation of local possession authorities is a systemic issue.
The ATSB is monitoring the safety actions proposed by Sydney Trains in response to Safety Recommendation RO-2014-017-SR055 and the underlying safety issue (RO-2013- 017-SI-02). The ATSB has sought periodic updates from Sydney Trains as to their implementation of the advised action, and will continue to monitor the issue by way of safety occurrence reports and the REPCON system.
In a response to the ATSB's inquiry as to Sydney Trains' progress with their advised safety action, the ATSB have been advised that the issue (RO-2013-017-SI-02) has been entered into the internal safety action management (SAM) system for progression and monitoring. Sydney Trains also noted that 'work on track' audio files, including those relating to Local Possession Authorities are already randomly monitored.
Sydney Trains stated: The Manager Network Rules & Projects has listened to and reviewed audio recordings from 12 randomly selected LPAs in relation to the transaction between Train Controllers, Signallers and PPOs when requesting and authorising LPA’s. He determined that in all instances a read back process was followed. However, the conversations were undertaken with varying levels of quality and accuracy.
Sydney Trains’ Network Operations Division has commenced a ‘Safety Critical Communications Project’, sponsored by the Director Operations and managed by the Manager Operations Compliance and Assurance. The aim of the project is to improving safety critical communications on the Network through more extensive monitoring, review and feedback to staff regarding safety critical communications. The project will also include a review of the existing Network Standard and Network Rules and Procedures relating to safety critical communications and an improved training and coaching regime. The focus of the project will be the reading back of safety critical communication and the training of Signallers and Train Controllers to take the lead in these conversations, especially in relation to prompting and leading the read back process.
The Australian Transport Safety Bureau is satisfied that the action taken by Sydney Trains has adequately addressed the safety issue.
Sydney Trains stated: The recommendation was assigned to the A/GM Safety & Accreditation (Matthew Coates). In order to satisfy this recommendation targeted reviews of LPA implementation are underway with the recommendation currently on target for close out by COB 14 September 2015.
Sydney Trains acknowledges that the inaccuracy of the Special Train Notice (STN) and relevant rules and procedures not being followed during implementation of the LPA were contributing factors to this incident. Sydney Trains undertakes assurance activities in relation to safety critical communications; these include checking of audio recordings of these conversations.
Sydney Trains proposes to undertake targeted assurance in relation to adherence to safety critical communications protocols in LPAs in order to determine whether the non-compliance's revealed in this investigation represent a systemic failure. Should systemic failures be identified further investigation will be undertaken.
The Australian Transport Safety Bureau recommends that Sydney Trains takes further safety action to address to what extent the inherent safety and efficiency of Local Possession Authorities can be compromised by non-compliance with rules and procedures by key stakeholders and if evident, whether they represent a systemic failure.
