Safety issue

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.

Number

RO-2014-001-SR-026

Organisation

Sydney Trains

Recommendation

The ATSB 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 must be included in the training of all operational Rail Management Centre (RMC) staff and all positions which may be required to adopt this role.

Released

3 December 2015

Final action

17 June 2021

Final action

Sydney Trains accepted the recommendation and advised ATSB that a revision to its Incident Management Framework amended Part 3 to state: ‘Before the Rail Commander arrives on-site, the “Officer in Charge” (e.g. Train Driver, Station Manager, Infrastructure, Facilities or Maintenance Centre Manager) is responsible for first response activities and to be the point of contact for the Rail Management Centre (RMC). Upon arrival of the Rail Commander, the Officer in Charge hands over to the Rail Commander…’

The recommendation has been partially addressed.

Safety issue

The rostering of the driver in the days leading up to the incident was inconsistent with Sydney Trains' rostering principles.

Number

RO-2018-004-SR-020

Organisation

Sydney Trains

Recommendation

The ATSB recommends that Sydney Trains take safety action to ensure that existing procedures regarding adequate rest breaks between shift cycles and start time rotations are reinforced to safeguard against fatigue impairment of train crew.

Released

20 December 2019

Final action

13 October 2020

Final action

Sydney Trains provided the following information about the action it has taken regarding this safety issue:

• Train Crew rosters are designed in accordance with SMS Rostering Principles as detailed in SMS-08-OP-3128 Managing Shift Work and Rostering at master roster level with controls in place at period roster level. Where there is departure from the rostering principles owing to operational requirements, fatigue risk control measures are identified and implemented as part of a risk management approach which includes consultation with affected workers.
• Train Crew specific procedures such as STOTC-14-005 Train Crew Fatigue Management Procedure (which references Sydney Trains’ fatigue management systems), the Guards Rostering and Working Arrangements (GRWA) document and Drivers Working and Rostering Arrangements (DRWA) documents provide a level of operational and employee flexibility and control. Train Crew manage potential fatigue and other lifestyle issues primarily to the intent of these documents.
• The offer of overtime that creates a deviation from the rostering principles is facilitated in these procedures and arrangements and requires acknowledgment by the Train Crew to the Rostering Officer that they are OK to work the offered shift.
• The Sydney Trains Fatigue Risk Management Improvement Program (FRMIP) Phase 1 (Technical Development) provided for, among other things, developing a revised and improved Fatigue Risk Management System (FRMS). Phase 2 (Change Management) involves communication of the improved FRMS to all relevant business areas within Sydney Trains. The business units are expected to resource and workshop the FRMS in order to effectively enable, and sustain, its implementation for their specific needs.
• Strategy, Portfolio and Investment Directorate (SPID) has been tasked by Sydney Trains Executive to establish a governance framework and a governance lead to manage the second phase (Change Management) of the FRMIP.
• As part of the change management process, the Fatigue Management Control System (FMCS) is in the final stages of deployment with a target of end of 2020. As part of the deployment, integration plans for a number of nominated business areas are being developed to integrate the FMCS into their specific rostering practices. This will inform the progressive rollout of the FMCS across the organisation which will enhance the ability for the relevant business areas to more readily identify the possibility of a rostering principle deviation and provide improved opportunities for the business areas to respond and manage the situation. Starting initially with ‘Shift Length’ and ‘Rest Between Shifts’ the FMCS will eventually cover all of the revised rostering principles detailed in the FRMIP.

The ATSB is satisfied that the action taken by Sydney Trains addresses this safety issue.

Safety issue

Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of strap breakage due to contact with the cradle.

Number

RO-2018-008-SR-040

Organisation

Pacific National Pty Ltd

Recommendation

The ATSB recommends that Pacific National address the risk presented by continuing to allow jumbo coils to be loaded in an orientation where all the radial straps are positioned within the contact zone between the coil and cradle.

Released

10 December 2020

Final action

5 May 2021

Final action

Pacific National engineers briefed the ATSB on the results of further work. The briefing addressed the four items indicated in correspondence dated 30 March 2021.

Pacific National also told the ATSB that all cradles, demountable and fixed, are being fitted with rubber load mat and that details of the mat and the requirement to inspect and maintain have been included in a draft (currently being reviewed for implementation) section of their Wagon Maintenance Manual.

Safety issue

Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose.

Number

RO-2018-008-SR-042

Organisation

Pacific National Pty Ltd

Recommendation

The ATSB recommends that Pacific National review the load restraint system provided by the demountable cradle design to demonstrate that they sufficiently restrain jumbo coils against lateral accelerations and prevent coils from moving and falling during transit.

Released

10 December 2020

Final action

5 May 2021

Final action

Pacific National engineers briefed the ATSB on the results of further work. The briefing addressed the four items indicated in correspondence dated 30 March 2021. Pacific National has indicated that it believes, based on calculations and measured data, that its jumbo coil carrying demountable cradles provide, at minimum, restraint capable of resisting about 0.75 g acceleration. This was greater than the actual accelerations measured by instrumentation during operation, at about 0.3 g typical (0.372 g maximum peak). Therefore, Pacific National stated that the level of load restraint offered by current demountable cradles demonstrates that they sufficiently restrain jumbo coils against lateral accelerations and prevent coils from moving and falling during transit.