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Pacific National limited risk controls for driver only operations
Date issue released
Safety Issue Description

Pacific National had limited controls for managing the risk of signals passed at danger during driver only operations, including incidents associated with driver fatigue. The safety system relied on a single driver correctly observing and responding to signals at all times, including during the window of the circadian low (when fatigue risk is greatest).

Issue number
RO-2019-022-SI-02
Issue Status
Closed – Adequately addressed
Transport Function
Rail: Freight
Issue Owner
Pacific National
Mode of Transport
Rail
Issue Status Justification

The ATSB is satisfied that the action being taken by Pacific National has reduced the risk of this safety issue.

Proactive action
Action number
RO-2019-022-PSA-193
Organisation
Pacific National
Action Status
Closed
Action description

Pacific National advised on 6 February 2020 that it had implemented the following proactive safety actions:

  • A risk assessment was undertaken to address new identified hazards and permit restart of operations.
  • A risk assessment and safety case was undertaken regarding night operations between 0001 and 0600, identifying additional interim controls that were implemented on driver only operated train services between Perth–Kalgoorlie and Port Augusta–Adelaide. These controls included:
    • addition of a second person in the cab between 0001 and 0600
    • a check-in process every 30–45 minutes if a service extended after 0001 due to out‑of‑course running
    • a requirement to maintain radio volume at audible levels.

Pacific National advised in November 2023 that it had implemented the following additional proactive safety actions:

  • Pacific National installed random time vigilance on all NR class locomotives (aimed at providing greater assurance that a driver is acknowledging vigilance compared to when using a standard vigilance cycle).
  • Pacific National conducted a workplace trial of a wearable fatigue-monitoring device to monitor the fatigue levels of drivers. The trial aimed to review the device’s suitability and appropriateness. It reported that, although the trial provided important feedback, the device was not deemed adequately reliable as a risk control for broader implementation for its operations.
  • Pacific National conducted a workplace trial of signal detection technology. The trial aimed to review the device’s suitability and appropriateness. It reported that, although the trial provided important feedback, the device was not deemed adequately reliable as a risk control for broader implementation for its operations.

Pacific National has engaged in an enforceable voluntary undertaking (EVU) with the Office of the National Rail Safety Regulator (ONRSR), accepted by ONRSR in May 2023 (see ONRSR website). Pacific National advised that the commitments in the EVU underpin the actions that Pacific National has committed to that align to the findings made by the ATSB. Some of these actions will address fatigue management (see also safety issues RO-2019-022-SI-01 and RO‑2019-022-SI-06).