Sydney Trains validation processes were not effective in detecting errors in Special Train Notice (STN) 1004 prior to the Local Possession Authority (LPA) implementation.
The Australian Transport Safety Bureau is satisfied that the action taken by Sydney Trains adequately addresses the safety issue.
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 has implemented a number of changes to their STN production and validation processes and incorporated new tools and systems to improve the integrity of the validation process and make it easier to independently assess possession information.
The Australian Transport Safety Bureau is satisfied that the action taken by Sydney Trains addresses this safety issue.
Sydney Trains drew our attention to page 23 of the draft report. At this point the draft report acknowledged that the Tran Planning Unit (responsible for the development and publication of STNs) had implemented a number of process changes based on their internal investigation of this incident; these changes were then listed and the report noted that the Train Planning Unit had ‘….implemented a number of changes to strengthen their production and validation processes.”
Since that initial information was supplied to the ATSB a number of other changes have been made to further strengthen the production and validation processes. These were:
Sydney Trains drew our attention to page 23 of the draft report. At this point the draft report acknowledged that the Tran Planning Unit (responsible for the development and publication of STNs) had implemented a number of process changes based on their internal investigation of this incident; these changes were then listed and the report noted that the Train Planning Unit had ‘….implemented a number of changes to strengthen their production and validation processes.”
Since that initial information was supplied to the ATSB a number of other changes have been made to further strengthen the production and validation processes. These were: