On 14 November 2023, Queensland Rail (QR) advised the ATSB that it had identified similar findings in its investigation report. It also advised that, as part of an enforceable voluntary undertaking (EVU) to ONRSR, it had introduced and completed initiatives relevant to this safety issue. The EVU initiatives relevant to this ATSB safety issue are:
1a) Improve planning and communication between track workers and Network Control Officers (NCOs) in SEQ
• This initiative improved planning and track access control. It has resulted in safety critical information regarding track work to be undertaken being communicated early to the Protection Officer. This will result in less time pressures and changes to track protection on the day of operations, which is prone to errors and increased safety risk.
1b) Implement Track Access System (TAS)
• This initiative will provide a common interface between the Network Control Officer and Protection Officer which will reduce the risk of communication errors and incorrect application of Work on Track Authorities. The system will allow infield workers to validate the correct implementation of blocking facilities and has potential for efficiency gains therefore reducing workloads of rail safety workers.
2a) Queensland Network Rules & Procedures (QNRP)
• Queensland Rail has undertaken extensive cross business collaboration and consultation over the past three years to simplify and refine its track and trackside safety rules and procedures. Changes involved replacing several different authority types for conducting work during normal business operations to a single “Track Authority”, with protection aligned to tasks and location (i.e., risk). All workers who plan and apply track protection have undergone training as part of the transition to the new rules, which included reinforcement of safety critical elements and principles.
3a) Improve trackside Pre-start Briefings
• This initiative reviewed the existing pre-start briefing training and upskilled workers in identifying and communicating site specific hazards and controls.
3b & 3c) Non-Technical Skills Development Program (NTSDP) for Protection Officers and Trackside Worksite Supervisors
• This initiative improved and upskilled Protection Officers and Trackside Worksite Supervisors in non-technical safety skills. The training has used this incident as a case study.
4b) Safety critical communications
• This initiative has resulted in an organisationally consistent assurance tool and supporting process for assessing both technical and non-technical components of communications between Network Control Officers and Protection Officers during the application of Work on Track Authorities.
In addition to the EVU initiatives, QR has also advised of the following actions related to this safety issue:
• Redeveloped the Protection Officer training package. This consisted of a transition product to support introduction of the revised QNRP and a new full PO course.
• Targeted PO Communications content on specific PO HUB page (with access for external PO’s) with a reference to communications and investigations lessons learned for the Thorneside incident.
• Communication training for all workers in corridor. This training focused on the delivery of effective pre-start briefings and was rolled out across SEQ and Regional work groups during 2020/2021.
• Implementation of ongoing Safety critical communication assurance across the business to review a sample of communications between NCOs and POs to ensure the effective use of rail-specific terminology and a range of other technical and nontechnical skills when communicating safety-critical information.
• Completed a 2nd line assurance activity 202021-021 Prestart Process Effectiveness Check to measure the effectiveness of the improved pre-start process. The overall control effectiveness of this assurance activity was deemed substantially effective, with two actions developed regarding pre-start specific safety interactions and the scheduling of an additional 2nd line assurance activity to monitor control effectiveness in the longer term.
