The lack of an appointed Officer in Charge of the incident site prior to the arrival of an Incident Rail Commander led to a fragmented response with no single employee having a recognised leadership role on site.
At the time of the report release, ATSB considers Sydney Trains proactive safety action does not fully address the safety issue.
To examine the demand for sufficient incident response commanders and expeditiously act to fill any identified vacancies.
The Australian Transport Safety Bureau considers that Sydney Trains’ proactive safety action does not address the safety issue in its entirety. An adequate availability of IRC personnel should lessen the response time to have an IRC attend an incident site. However, the matter of not appointing an Officer in Charge until the arrival of the IRC has not been addressed.
The Australian Transport Safety Bureau recommends that Sydney Trains, through a revision to its Incident Management Framework, adopts the positive appointment of an Officer in Charge for Level 2, 3 & 4 incidents once they have been reported. This requirement and the functions of an Officer in Charge should be included in the training of all operational RMC staff and all positions which may be required to adopt this role.
