Sydney Trains assurance and audit processes for signal box management did not routinely detect non-conformances with NTR 432.
The ATSB is satisfied that the safety action undertaken by the operator has resolved this safety issue
Sydney Trains accepts this safety issue and advises that:
Line managers have been required to focus safety engagements, undertaken with signallers, on ensuring signaller understanding of NTR 432. If non-conformances are identified remedial coaching/training will be undertaken with the signaller.
From 18 November 2022 all Signallers have been instructed to report each use of NTR432 to their line manager and line managers have been instructed to submit an audio compliance request for all reported uses of NTR432 for a compliance review.
