There were no formal systems in place to manage the accepted practice of Protection Officers leaving a work site to return a Track Warrant and Train Staff, prior to ceasing works, off-tracking and ensuring the line was clear. This practice led to the informal delegation of responsibility for ensuring the track was clear to others at the work site.
ATSB is satisfied that the safety actions taken by V/Line following this incident combined with other actions under way (refer Additional safety actions) will reduce the risk of track maintenance equipment remaining on track when Track Force personnel are clearing a line for the passage of rail traffic.
As a result of this incident and other related Safeworking incidents, V/Line has completed a ‘Take 5’ (stand down day) where work was halted to review and discuss the following topics with major works and maintenance personnel workers.
As part of its ‘Destination Zero Strategy’ (refer Additional Safety actions) and particularly pertinent to this incident, a Track Worker Safety Review has been commenced. This involves a review of tasks, rules, procedures, and training for works. It includes a review of the levels for Safeworking and rules for infrastructure works.
