Public Safety Annual Safety Review 2008

www.ptsv.vic.gov.au 2007-08 performance outcomes 2007-08 performance outcomes

In 2007-08 PTSV set out to achieve a project-based program of work consisting of five key outcome areas. These key areas are: > effective regulatory intervention > improved systems and > solve problems through proactive and reactive risk-based approach > promote and deliver targeted communication and education > create a work environment that attracts, develops and retains highly skilled and motivated people.

Some of the highlights resulting from these outcomes include: > PTSV’s accreditation of all commercial AROs to the Rail Safety Act 2006 (RSA) by 30 June 2008, as stated in . > Exceeding all of PTSV’s performance targets for 2007-08. > Successful implementation of 76 percent of the project deliverables. > Contributing to the Department of Transport’s Division’s review of the current regulatory framework, which resulted in a discussion paper being distributed for comment and the draft bus safety bill. PTSV accredited all commercial > Contributing to the National Reform Agenda, particularly AROs to the Rail Safety Act 2006 development of the National Guideline for Accreditation and the National Compliance and Enforcement for Rail Safety. by 30 June 2008. > All operations staff using the Transport Safety Accreditation and Audit Reporting System. > Comprehensive review of PTSV’s policy and procedure management system. > Establishing a brand for PTSV through the implementation of the separate PTSV website, uniforms for field officers, regular communications through newsletters and email alerts. > Continuing the Transport Safety Officer training and including sharing experiences with other state rail safety regulators.

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Contents 2007-08 performance outcomes 1 Director’s foreword 4 Our vision and mandate 6 Corporate overview 8 Rail 16 Bus 26 Enhancing performance 34 Outlook 36 Appendices 40 Appendix 1 – Progress against 2007-08 outlook 42 Appendix 2 – Heavy rail safety statistics 43 Appendix 3 – safety statistics 44 Appendix 4 – Bus safety statistics 45 Appendix 5 – Significant train/tram/bus incidents 46 Appendix 6 – Output performance measures 47 Appendix 7 – Freedom of Information 47 Appendix 8 – Complaints and enquiries 48 Appendix 9 – Analysis of PTSV’s website 48 Appendix 10 – Risk attestation 48

Acronyms ARO Accredited Rail Operator ASR Annual Safety Review ARA Australasian Railway Association ADRs Australian Design Rules APTG Australian Public Transport Group CFF Contributing Factors Framework DCQP Data Collection Quality Project DOT Department of Transport DOTARS Department of Transport and Regional Services ERS Electronic Reporting System ITSRR Independent Transport Safety and Reliability Regulator LBT Licensed Bus Tester MMS Maintenance Management System MORT Management Oversight and Risk Tree NTC National Transport Commission PTSV Public Transport Safety Victoria RISSB Rail Safety and Standards Board RRM Rail Resource Management RSA Rail Safety Act 2006 RSCP Rail Safety Compliance Program RSRP Rail Safety Regulators’ Panel RTBU Rail Tram and Bus Union SIA Safety interface agreements SMS Safety Management System SPAD Signals passed at danger TSO Transport Safety Officer

3 Director’s foreword Director’s foreword

PTSV has been Victoria’s independent public transport safety regulator for two years now, in which time a great deal has been achieved. The commercial rail operators have been reaccredited following a transition period and PTSV undertook a careful and considered approach to reaccreditation to ensure the operators were embracing the new legislation. I am very pleased to say they have delivered. This process continues for the tourist and heritage operators who have until July 2009 to fully embrace the new legislation. Progress to date is encouraging. Going forward into 2009, after consultation with the industry, PTSV will introduce a new way of carrying out its compliance inspections and audits. In doing that we will use what we have learned from the reaccreditation process and our understanding of safety risk to profile what we focus on within the accredited From a safety regulatory operators. PTSV is also taking an active role in the metropolitan refranchising process to ensure Victoria achieves the best safety perspective, Victorians can be outcomes it can from the process. I am also looking forward to seeing the benefits of the Victorian operators’ efforts in confident PTSV has in place implementing the National Contributing Factors Framework in modern regulatory processes 2009 as part of their investigation processes. We are now also a step closer to having a new Bus Safety Act that that reflect the contemporary will provide the industry and PTSV with modern, risk-based safety legislation. As I said in last year’s review, the bus industry has a very rail safety legislation put in good safety record but we cannot afford to stand still, particularly given the growth in patronage over the past two years. Even while place by the State . we await to see the final shape of the new legislation, progress is being made on improving systems, including work on Licensed Bus Testers and the new Bus Operator Help Kit highlighted in this review. Patronage on Victoria’s public transport system continues to record double digit growth with over 30 percent growth over the last three years. From a safety regulatory perspective, Victorians can be confident PTSV has in place modern regulatory processes that reflect the contemporary rail safety legislation put in place by the State Government. PTSV’s staff continue to do their jobs with dedication and commitment and I would like to thank them for routinely exceeding expectations. Once the bus safety legislation is in place this will complete the safety legislative reform for Victoria’s public transport system. PTSV looks forward to building on the successes to date and, where required, holding the Victorian accredited operators to account in continuing to improve safety performance.

Alan Osborne Director, Public Transport Safety

5 Vision To be a respected transport safety regulator who is proactive and risk based. Mandate To continuously improve the safety of public transport in Victoria. Our vision and mandate We will achieve this through: > effective regulatory > promoting and intervention delivering timely > improving systems targeted and governance communication > solving problems through > a collaborative proactive and reactive workplace culture

7 Corporate overview Governance

The Director, Public Transport Safety was established by the to regulate the safety of train, tram and bus operations in Victoria. More specific legislation is now in place for railway safety (Rail Safety Act 2006), while bus safety is regulated under the Public Transport Competition Act 1995. New bus safety legislation is being developed that is likely to be similar to the rail safety legislation. The Director, Public Transport Safety reports to the Minister for Public Transport. PTSV is administratively linked to the newly established Department of Transport (DOT) and utilises its IT, financial and human resources. PTSV’s decisions and determinations are independent of the DOT and further measures are being put in place to ensure this independence is continuously assured.

Did you know? > Victoria’s rail (train and tram) is ’s second largest > Rail patronage within Victoria grew 13.2% in 2007-08 – up from 187,440,000 to 212,209,000 > There are approximately 7,502 in Victoria > An average of 7,500 annual bus inspections are conducted every year in Victoria by Licensed Bus Testers

9 Background

Rail industry Victoria’s rail (tram and train) network is Australia’s second largest, comprising 23 commercial and 19 tourist and heritage accredited operators. These commercial operators provide passenger (metropolitan and regional) and freight rail services. Operators can be accredited as rolling stock operators and/or rail infrastructure managers. The franchises currently held by Connex and Yarra are being re-tendered in 2008-09. PTSV will act as an adviser to ensure safety is considered throughout the refranchising process. PTSV will assess the successful franchisees for their competency and capacity with regard to rail safety.

Bus industry Victoria’s bus industry consists of 1,508 accredited bus operators; 907 of whom offer school, route, and tour and services. A proportion of these commercial accredited operators hold contracts with either the DOT or the Department of Education and Early Childhood Development. The remaining 601 accredited operators are non-commercial operators. These operators provide private, courtesy and hire and drive services. There are approximately 7,502 buses in Victoria. A review of the existing bus safety legislation (the Public Transport Competition Act 1995) is currently underway to ensure bus safety in Victoria more closely reflects the State Government’s policy directions. It is anticipated the revised bus legislation will give PTSV similar compliance, enforcement and education powers to those used in the rail industry.

Role of PTSV PTSV’s purpose is to facilitate and promote the highest standards of public transport safety by creating a framework within which industry effectively manages risk. PTSV achieves this through the safety accreditation of rail and bus operators, and monitoring their compliance with bus and rail safety legislation through a system of compliance inspections, audits and investigations. PTSV is also a source of advice and guidance for industry with regard to safety management and the responsibilities for operators under the rail safety legislation. PTSV also facilitates continuous improvement of rail and bus safety by monitoring incident/accident data to identify trends and issues, and representing Victoria in the development of national safety protocols, procedures and guidelines that will enable a consistent approach to safety regulation across Australia.

PTSV’s purpose is to facilitate and promote the highest standards of public transport safety by creating a framework within which industry effectively manages risk. Our organisation

PTSV’s 65 staff are responsible for regulating the 1,508 accredited bus operators and 23 commercial and 19 tourist and heritage accredited rail operators. In 2007-08 PTSV relocated its office to the Southern Cross Building at 121 Exhibition Street. PTSV also has four bus safety officers located across regional Victoria in Benalla, Bendigo, and Traralgon. PTSV’s bus and rail operations staff also travel across Victoria to audit rail and bus operators and conduct compliance inspections. In 2007-08 PTSV further refined its organisational structure to better reflect the regulatory activities it undertakes. The organisational structure has undergone four key changes: 1. The Regulatory Policy and Legal (RPL) teams were amalgamated to better equip PTSV to meet the challenges of the National Reform Agenda, the subsequent implementation of the RSA and review of the bus regulatory framework. RPL is headed by PTSV’s Legal Counsel under the title of Manager, Regulatory Policy and Legal, and has legal and policy officers. RPL works across PTSV to advise on legal issues and establish policy positions, particularly those that articulate the use of statutory discretion, and provide a conduit to other parts of government on legal, legislative and policy matters. 2. Over the past two years PTSV’s education and training has focused on developing regulatory staff to undertake the work needed to meet PTSV’s obligations under the RSA. During this period PTSV’s Project Manager, Training and Education reported to the General Manager Safety Operations. In late 2007-08, with the two-year anniversary of the RSA approaching, it was decided that training and education should be more broadly focused for all of PTSV staff. Accordingly, the Project Manager, Training and Education now reports to the Business Manager. PTSV realises that if it is to reach its vision of becoming a respected, proactive and risk-based transport safety regulator it needs to continue to invest in its resources. 3. In 2007-08 PTSV created nine new positions to assist it achieve its objectives of improving its systems and governance and effective regulatory intervention. 4. PTSV’s approach to investigations changed due to the Organisational snapshot development of the Office of the Chief investigator. PTSV now Table of establishment figures as at 30 June 2008: carries out its investigations using multi-disciplinary teams from across PTSV rather than having a dedicated team solely Male Female focused on investigations. Executive management 3 3 In 2007-08 PTSV had a staff turnover rate of 16.7 percent, lower Management 4 5 than previous years. As Victoria was the first state to implement the Staff 26 18 rail national model legislation the experience of its staff are likely to be of interest to other public transport regulators. So it is probable As of 30 June 2008, five out of the six vacant positions that this level of staff turnover will continue. in PTSV were in the process of being recruited.

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Training and education

Over the past two years PTSV has heavily focused its education and training resources on establishing a comprehensive training program to equip regulatory staff, particularly Transport Safety Officers (TSO), with the skills and competencies to discharge their regulatory duties. To become a TSO* all field staff must undertake a four-day TSO training course designed to understand their duties and responsibilities under the Rail Safety Act and 2006. In the past financial year, 16 PTSV staff attained TSO status. PTSV’s experience in conducting the TSO training was of particular interest to rail regulatory staff from other , with 14 staff from interstate rail regulators also undertaking the course in 2007-08. In 2007-08 regulatory staff participated in a total of 29 different courses. Qualifications, other than the TSO training, attained by PTSV’s experience in conducting PTSV staff last year were: the TSO training was of particular > Diploma of Government (attained by 10 staff members) > Diploma of Business (Quality Auditing) (attained by three staff) interest to rail regulatory staff > Certificate IV in Training and Assessment (attained by four staff). from other jurisdictions, with Other training courses in which PTSV staff participated included: 14 staff from interstate rail > Effective report writing skills for auditors > Negotiation and communication skills regulators also undertaking the > Conflict resolution course in 2007-08. > Human factors training. The PTSV training and education program is continually reviewed to ensure it aligns with PTSV’s strategic objectives.

Human factors training The role of human factors in contributing to serious rail safety occurrences is well established. It is therefore important PTSV staff are fully equipped with the knowledge and tools to understand these issues. In 2007, a project was initiated to develop PTSV staff’s awareness training in human factors. Two modules were developed and delivered of the role of human factors in the public transport environment. The first module, Basic Human Factors, provided information about the basic concepts in human factors, how it applies to transport safety and how it is relates to functions, teams and roles in PTSV. The second module, Safety Management Systems and Human Factors, provided participants with an understanding of human factors integration in safety management systems and in public transport projects. It also specifically considered how fatigue affects safety and how it can be addressed in a fatigue management system. Further modules in human error and safety culture, including just culture and safety leadership, will be delivered in 2008-09. It is intended the training will be extended to other stakeholders.

* A TSO is a person appointed by the Safety Director under the Transport Act 1983 to exercise certain powers under transport safety . 13 2007-08 achievements The 2007-08 outcomes selected were aligned to PTSV’s mandate and vision and were ambitious, challenging and designed to be PTSV program of work for 2007-08 focused on three key areas: achieved over three years. The projects enabled PTSV to move closer to achieving the intended outcomes. Of the 44 projects > The successful implementation and administration of the RSA, designed to help PTSV achieve these outcomes, 76 percent > continuing to improve our bus safety regulatory activities ahead were completed during the year. of the new bus safety legislation, and PTSV developed a project management framework to ensure it > the implementation of a project-based approach to improving our effectively managed risks to successful delivery of the projects and regulatory activities. the organisation’s outcomes listed in the 2007-08 business plan. In 2007-08, PTSV strategically designed 44 projects from its As a result, PTSV’s Executive Committee monitored the progress and business plan to help it achieve its five key organisational outcomes. risks of each project on a monthly basis throughout the 2007-08 The five outcomes of these projects include: financial year. The framework has been reviewed and refined for the 2008-09 financial year. Outcome 1: Effective regulatory intervention PTSV continued the implementation of the Rail Safety Act 2006, with the accreditation of all commercial operators, as specified in the legislation, and the development of a transitional plan for tourist and heritage operators to become reaccredited by 30 June 2009. PTSV also supported the DOT’s Public Transport Division’s review of the current bus legislative framework by contributing to the discussion paper on bus safety issues.

Outcome 2: Improved systems and governance The Knowledgebase Review Project enabled PTSV to audit and review all of its and procedures in its management system. The 2007-08 outcomes selected During the process it became apparent a new user interface was needed, resulting in the development of an intranet-based system were aligned to PTSV’s vision and from which PTSV policies and procedures can be accessed. mandate and were ambitious, In the past year, PTSV played an active role in the National Reform Agenda. Victoria significantly contributed to the development challenging and designed to be of supporting regulatory guidelines coordinated by the National Transport Commission (NTC), particularly the National Guideline for achieved over a number of years. Accreditation and the National Compliance and Enforcement Policy for Rail Safety.

Outcome 3: Solve problems through proactive and reactive risk based approach A risk model assists PTSV to achieve risk-based regulation in the rail industry. It is one of many of the intelligence gathering and analysis tools PTSV uses to conduct risk-based audit and compliance activities. The tool has been developed to assist regulatory staff identify and rank areas of high risk in order to conduct targeted compliance inspections.

Outcome 4: Promote and deliver targeted communication and education Development of a number of key communication tools has been a focus during 2007-08 for PTSV. These included a PTSV website, development of a PTSV brand and visual identity, regular newsletters for the rail and bus industries, email subscriptions to stakeholders, stakeholder forums, the inaugural Annual Safety Review, and the design and issuing of uniforms to all PTSV field staff.

Outcome 5: Create a work environment that attracts, develops and retains highly skilled and motivated people A strong focus over 2007-08 has been the PTSV skill building program for safety operational staff, which included training enabling them to undertake roles as TSOs. National rail issues Summary of Safety Alerts

The push by some rail operators and the Australasian Railway issued 2007-08 Association (ARA) for a single national rail safety regulator Safety Alerts are a communications tool that PTSV uses continued in 2007-08, and PTSV had an active role in providing to advise rail operators of critical safety information. information to the NTC on this and the Regulatory Impact Statement. They are issued to rail operators via email as required. This assistance will continue into 2008-09. During 2007-08 PTSV issued the following Safety Alerts The NTC’s Rail Safety Package Steering Committee was disbanded to Victoria’s rail operators: following the completion of the national rail safety model legislation. As at June 2008 Victoria remained the only State Date Safety Alert No. Topic to have commenced operation of the national model legislation, 2 July 2007 2007-06 Wrong side failure of tri colour while other States and the are at various LED signal (RM4 TRFB-75A) stages of implementation. 10 Oct 2007 2007-07 Transport Accident Investigation Rail Safety Regulators’ Panel Commission (NZ) investigation The Rail Safety Regulators’ Panel has continued a very full program into the loss of air brakes and of work to assist the national process. The Panel met in Sydney collision of a W-Class tram (August 2007), Hobart (November 2007), Brisbane (February 10 Oct 2007 2007-08 Heavy vehicle clearance times 2008) and Darwin (May 2008). Victoria continues to support the at level crossings Panel’s work. 30 Nov 2007 2007-09 Cracks in the muff couplings Projects in 2007-08 included chairing the Contributing Factors 19 Dec 2007 2007-08 Wrong side failure of tri colour Framework group, input to the development and roll out of the LED signal (RM4 TRFB) updated ONS1, as well as a number of national guidelines relevant 29 April 2008 2008-01 Murray Key Retainer Pin to the national model legislation. 2 May 2008 2008-02 Securing of redundant air brake During the year PTSV has valued the opportunity to continue the hoses on locomotives development of positive links between staff in the offices of the other Australian rail safety regulators. For example, PTSV has 2 June 2008 2008-03 Claw Lock Castings welcomed operational staff from other offices to participate in 5 June 2008 2008-04 Rail defect management the compliance training that the organisation has developed for 24 June 2008 2008-05 Accident investigation – prospective transport safety officers. In turn, PTSV has valued Mindi the opportunity to benefit from their practical experience, as well as gaining a better understanding of the different operating environments in which the organisations each work.

Legislative amendments The Rail Safety Act and the Transport Act were amended during the year. Reasons for the amendments were: > To incorporate amendments to the NTC’s national model legislation, or to improve substantive consistency with that legislation, for example, the provisions relating to safety interface agreements. > To clarify ambiguities, for example, provisions relating to labour- hire companies. > To refine or improve the operation of the legislation, for example, permitting the Safety Director to delegate his or her functions and powers. A chart listing the amendments and the dates on which they take effect is published at www.ptsv.vic.gov.au

As at 30 June, Victoria remains the only state to have commenced operation of the national model legislation. 15 Rail Rail

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Rail audit and compliance activities Tram-tram collisions PTSV attended two tram-tram collision incidents and two tram for 2007-08 derailments. These resulted in a further compliance inspection to determine whether was complying with rail safety In 2007-08 PTSV conducted more compliance inspections legislation requirements in relation to instruction, training and than in 2006-07. supervision of drivers to perform their role safely. In addition, the From November 2007 changes to legislation meant PTSV is no inspection sought to ascertain if the trams involved in the incident(s) longer required to conduct annual audits and as a result has moved were maintained in accordance with the rail operator’s SMS. to a risk-based Rail Safety Compliance Program (RSCP). Accordingly, from January to July 2008 the rail compliance team focused on Infrastructure the verification process for the re-accreditation of all rail operators PTSV conducted nine inspections relating to infrastructure under the RSA. management. The focus of these included broken rails, track geometry, /signalling failures, rail buckles and rail 2006-07 2007-08 defects. These inspections were looking at “so far as is reasonably Rail safety audits 42 28 practicable” whether the operator: Rail compliance inspections 29 37 > provided or maintained rail infrastructure that is safe Rail verification inspections N/A 17 > provided or maintained systems of rail safety work that are safe Non-conformance reports raised 135 96 > provided information, instruction, training or supervision to rail safety workers as is necessary to enable those workers to Prohibition notices issued 0 1 perform their rail safety work in a safe manner. Improvement notices issued 13 5 New accreditations 6 0 Safeworking PTSV conducted four compliance inspections relating to safeworking Verification inspections incidents. These included shunting collisions and rail safety worker Seventeen verification inspections were conducted as part of injuries. These inspections were looking at whether the rail operator the reaccreditation process. A verification inspection involved a provided information, instruction, training or supervision to rail site verification of an operator’s implementation of their safety safety workers as is necessary to enable those workers to perform management system. their rail safety work in a safe manner. Findings generated from this process were key inputs into PTSV’s The remainder of inspections consisted of close-out of audit results 2008-09 Rail Safety Compliance Program. from 2006-07, fatigue management, rail safety worker health and fitness requirements, emergency management and rail safety Compliance inspections operational requirements. PTSV conducts compliance inspections to ascertain whether the Prohibition/improvement notices accredited rail operator is complying with the law – specifically Rail Safety Act 2006. A prohibition notice was issued against a rail operator on the movement of any rolling stock without being an accredited rolling The sections of the Act inspected are: stock operator, or an operator exempted from accreditation. > Section 20 (Duty of rail infrastructure manager to ensure the There were five improvement notices issued covering: safety of rail infrastructure operations) > failure to provide monthly reports (3 operators) > Section 21 (Duty of rolling stock operator to ensure the safety of rolling stock operations) > failure to submit an Annual Safety Report (1 operator) > Section 28 (Rail operator must comply with a safety > lack of management of change process in SMS (1 operator). management system).

Level crossings PTSV attended 10 fatal level crossing incidents. In all the compliance inspections, PTSV was investigating whether the: > safety signage was in accordance with the standard contained in the rail operator’s Safety Management System (SMS) > rail was maintained in accordance with the rail operator’s SMS > rolling stock was maintained in accordance with the rail operator’s SMS for actively protected level crossings > active protection was operating correctly at the time of the incident and maintained in accordance with the rail operator’s SMS.

19 Key rail achievements for 2007-08

New regulatory intervention program On behalf of the Director Public Transport Safety, PTSV is responsible for regulating rail safety in Victoria in accordance with the RSA. This includes monitoring whether rail operators are meeting their obligations to ensure the safety of their rail operations, so far as is reasonably practicable. The RSA provides the Director with a range of regulatory interventions for meeting his obligations, including the power to accredit rail operators; suspend or cancel accreditation; place conditions on a rail operator’s accreditation; audit and inspect rail operator safety management systems and operations; issue rail operators with Improvement Notices when an operator contravenes a transport safety law; prohibit rail operations if such operations represent an immediate risk to safety; and publicly releasing information if it is in the interest of public safety. The Safety Operations branch contributes to meeting the Director’s RSA obligations by planning and executing an annual program of risk-based safety audits and compliance inspections now known as the Rail Safety Compliance Program (RSCP). In addition, Safety Operations participates in inter-jurisdictional safety audits of interstate rail operators accredited in Victoria. For the purposes of resource management these inter-jurisdictional safety audits are also included in the RSCP. In developing the annual RSCP the PTSV planning committee, chaired by the General Manager Safety Operations, identified a number of priority safety risks judged by the committee worthy of PTSV’s regulatory attention during the forthcoming financial year. The committee also sets the regulatory compliance goals for the annual RSCP – that is the rail safety outcomes PTSV wishes to achieve through its regulatory compliance activities over the forthcoming financial year. Inputs to the RSCP include: > safety principles and objectives of RSA > PTSV’s Compliance and Enforcement Policy for Rail Safety > risk profile of AROs > National Audit Program > Catastrophic Risk Model > industry trends, and intelligence acquired by PTSV > areas deemed ‘of industry importance’ by the Director, PTSV or his/her management team > follow-ups required regarding corrective action arising out of safety audits and compliance inspections > follow-ups required regarding variations of accreditation and notifications of change > necessity to investigate compliance of an ARO’s activities as nominated by the ARO Manager > analysis of ARO Annual Safety Review Reports > analysis of railway accident/incident and notifiable occurrences reports, and > relevant safety trend analysis. The output of the planning process is the program of regulatory activities that will be undertaken during the forthcoming financial year. It consists of safety audits, compliance inspections, and topic inspections timed and targeted to achieve the regulatory compliance goals set by the planning committee. The RSCP commenced in the first quarter of 2008-09 with its first Re-accreditation of commercial rail operators quarter topic ‘Controls for Managing Risk’. Regulatory activities 1 July 2008 marked a significant achievement for railway safety during this quarter include compliance inspections on Connex, with all commercial rolling stock operators and rail infrastructure V/Line, Yarra Trams and Australian Rail Track covering managers operating in Victoria accredited under the RSA. The risks to safety such as disarrangement of overhead traction power two-year transition process has passed quickly with 23 accredited supplies and maintenance of rail bridges and culverts. The RSCP rail operators (AROs) previously accredited under the Transport Act includes formal planning committee assessment of each quarter’s 1983 successfully becoming accredited under the RSA. Substantial achievements and subsequent adjustments to regulatory activities work was required from AROs to submit material over several pre- to ensure PTSV continues to adequately monitor rail operators’ determined milestones. PTSV’s Rail Accreditation team assessed safety obligations. Further information on the Rail Safety Compliance and verified the material met the new RSA requirements. Program is available at www.ptsv.vic.gov.au. The process was undertaken in stages previously agreed with industry, with AROs achieving four milestones. Milestone 1 - December 2006: providing an Implementation Plan detailing the activities the ARO will undertake to meet the requirements of Division 2 of the RSA (Safety duties of rail infrastructure managers and rolling stock operators). Milestone 2 - February 2007: providing a Gap Analysis between the ARO’s current Safety Management System and the safety management requirements of Part 3 and Part 5 of the RSA and Schedule 2 of the Rail Safety Regulations 2006. 1 July 2008 marked a significant Milestone 3 - June 2007: providing their Risk Register and illustrating how the ARO’s risk register complies with Division 3 of achievement for railway safety Part 5 of the RSA. Milestone 4 - December 2007: providing a Compliance Report that with all commercial rolling stock addressed the accreditation requirements of Part 3 and Part 5 of the operators and rail infrastructure RSA, including an updated version of the ARO’s safety management system and risk register. managers operating in Victoria At each stage of the re-accreditation process, PTSV’s Rail Accreditation team assessed each ARO’s progress and provided accredited under the RSA. constructive feedback on areas requiring more work to comply with the requirements of the RSA. The re-accreditation process’ success was demonstrated by PTSV signing off all 23 new Notices of Accreditation before the old accreditations sunsetted on 30 June 2008.

Catastrophic Risk Model During 2006-07 a Catastrophic Risk Model was constructed for PTSV that identified and quantified key rail safety risks and their precursors to allow compliance resources to be targeted to areas of greatest risk. Work continued in 2007-08 on the quantification of risk associated to the collision with objects on rail lines other than at level crossings and risk associated with the use of catch points and derailers. The risks quantified by these two pieces of work have been incorporated into the Catastrophic Risk Model. A user interface for the Catastrophic Risk Model was also commissioned this year and PTSV compliance staff were trained in its use. Work continues on the quantification of rail safety risks not yet captured by the model, and in segmenting the model to allow use by accredited rail operators.

21 Key rail issues for 2007-08

Tram-tram collisions On 24 September 2007, Tram 3519 en route from the Malvern Terminus to the CBD on Route 6 collided with Tram 3522 at Stop 24 on St Kilda Road. During the following month two further collisions occurred under similar circumstances – on 16 October 2007, Tram 132 collided with Tram 196 at Stop 14 on St Kilda Road and on 23 October 2007, Tram 134 collided with Tram 2080 at Stop 20 on Flemington Road. The three collisions resulted in significant damage to the trams and several passengers were injured, some requiring transport to hospital, although all were released on the same day. Investigations into the cause of these incidents were undertaken by Yarra Trams and the Office of the Chief Investigator. PTSV conducted a compliance inspection to ascertain whether Yarra Trams was complying with the safety requirements of the RSA. While PTSV’s compliance inspections did not identify any contravention of transport safety law, it did highlight areas for improvement. In particular, opportunities to improve safety through the application of human factors knowledge and developments in vehicle collision avoidance technologies were highlighted to Yarra Trams. Since the above incidents, the number of serious tram-tram collisions has declined, however, instances of minor tram-tram collision – particularly when trams are being stabled over night – continue to occur. PTSV will continue to monitor Yarra Trams’ progress in improving safety in this area.

Siemens train braking Last year’s Annual Safety Review reported on the work undertaken by Connex, Siemens and PTSV in addressing the Siemens sliding train issue. Since lifting the express mode safety restriction in October 2007, Connex and Siemens have implemented a number of software modifications to the train braking system that have further improved the braking performance of the Siemens fleet. PTSV continues to closely monitor Connex’s actions to ensure the safe operation of the Siemens trains.

New Street gates On 10 September 2007 a metropolitan train collided with the level crossing gates at New Street in Brighton. Damage to the gates meant they could no longer perform their safety function and Connex decided to close the level crossing on public safety grounds. Fortunately, while the incident had significant potential for harm, it did not result in injury to either the signaller in charge of the gate’s operation or to members of the public. After careful consideration of the safety risks, Connex proposed to A wrong side failure of signalling the local council that either the gates be permanently closed and preserved as an historical artefact or the level crossing protection equipment is a significant be upgraded to modern boom gates, lights and bells. PTSV supports either of these options. event, as it can lead to a At the time of going to print, a decision on the future of the catastrophic incident, such as protection at the New Street level crossing had not been made and the crossing remains closed to motor vehicles. collision or derailment of a train. Wrong side failure of Tri-Colour LED signal V/Line trains in parts of the metropolitan system, signal circuitry changes at level crossings, placing flagmen and additional The Westinghouse Tri-Colour signal installed on the metropolitan signallers at key locations, speed restrictions in critical areas, and regional rail networks in Victoria became the subject of re-routing freight trains from lines that had the Tri-Colour Signals significant industry concern and activity during 2007-08. and block working on some lines. Controls were substantially in The Tri-Colour LED signal is a solid state device developed to place by 21 December 2007. replace the existing electromechanical searchlight signals. Tri-Colour signals utilise Light Emitting Diodes (LEDs) to display The greatest impact of these controls were on V/Line services on red, yellow and green aspects in a single unit. LED signals were the Gippsland line where trains were terminated at Pakenham developed as a replacement for conventional incandescent lights and passengers transferred to services provided by Connex trains. and offer the advantages of long life and low maintenance. Normal services on the Gippsland line resumed on 29 January 2008. Prototypes of the Westinghouse Tri-Colour Signal were first In January 2008 a Voluntary Recall Notice for the Tri-Colour signal demonstrated in 1999, at the time the former Public Transport was issued by Westinghouse. The introduction of the controls Corporation was being privatised. Type approval for the by Connex and V/Line allowed time to identify a suitable Westinghouse Tri-Colour Signal was issued in November 2000 replacement signal and to progressively withdraw this device allowing use of this device in the metropolitan rail network. from use on the Victorian rail network. A replacement signal was In November 2003, type approval for use of this device in the sourced by Connex and V/Line and was reviewed by a signal regional rail network was issued. These devices were progressively sighting committee (comprising the RTBU and the rail operators). installed along lines in both the metropolitan and regional PTSV also reviewed the safety integrity of the replacement signal. networks and they performed without incident until June 2007. The replacement program was risk based, ensuring the more On 27 June 2007, the first instance of a wrong side failure of this important locations were addressed first. Due to the availability of device occurred at Werribee. A wrong side failure of signalling suitable replacement units, this program was not completed until equipment is a significant event, as it can lead to a catastrophic June 2008. incident, such as collision or derailment of a train. V/Line immediately PTSV subsequently conducted an investigation to determine how replaced this signal and investigated the failure. PTSV issued a the Westinghouse Tri-Colour Signal came to be type approved for Safety Alert in July 2007 advising the rail industry of this incident. use in Victoria. The investigation is ongoing and will be completed On examination, the failed unit was found to have impact damage to in late 2008. the lens of the signal, allowing water ingress into the signal’s control circuitry, causing an internal short circuit. A second wrong side failure of this device occurred at Southern Cross Station on 16 December 2007. In this incident, the driver of a V/Line down Traralgon train reported that signal 116 at Southern Cross Station was showing a proceed aspect (green) when it should have been showing a stop aspect (red). After discussion with train control it was confirmed that the signal was defective and it was taken out of service for investigation. Unlike the incident at Werribee in June 2007, there was no sign of external damage to the failed unit. PTSV’s first priority was to ensure the risks to safety associated with this device were minimised. In its role as safety regulator, PTSV oversaw the response of affected rail infrastructure managers (V/Line and Connex) to this situation. PTSV attended the examination of the unit that failed at Southern Cross Station to understand why it failed and to determine the extent of the problem. It was apparent from this examination that there was an inherent design fault in the device that that affected all units in use. The design fault meant that the Westinghouse Tri-Colour Signal was not suitable for its intended application. PTSV issued a further Safety Alert in December 2007 to the rail industry providing details of this failure. At that time there were approximately 300 Westinghouse Tri-Colour signals in use on the Victorian rail network. Connex assessed each location where this signal was installed to identify the risks should the signal fail and to determine the appropriate risk mitigations. Connex, working cooperatively with V/Line, PTSV and the Rail Tram and Bus Union (RTBU), developed a suite of risk control actions. These controls included not running

23 Victorian heavy rail safety statistics

2003-04 2004-05 2005-06 2006-07 2007-08 5yr average Fatalities 13 10 16 22 15 15 Fatalities at level crossings 1 5 6 14 7 7 (collision with road vehicle) Fatalities at level crossings 3 3 5 3 4 4 (collision with person) Passenger fatalities 2 0 2 12 0 3 Fatal incidents 13 8 15 12 14 12 Serious injuries 24 14 75 165 125 81 Passenger serious injuries 19 6 36 116 93 54 Level crossings (near miss with person) 51 44 50 72 107 65 Level crossings (near miss with road 73 112 129 186 163 133 vehicle) Running line derailment 22 24 15 21 22 21 Running line collision 48 57 79 66 93 69 Running line train-train collisions 3 1 4 1 8 3 Signals passed at danger (SPAD) 206 149 155 169 197 175

Factors impacting on heavy rail statistics A broadening of the definition of serious injury, from 1 August 2006 The following initiatives impacted on PTSV’s data such that to 29 February 2008 resulted in a significant increase in reported increases have been observed over time: numbers. For the financial year 2007-08, 125 serious injuries were reported. Due to the changes in the definition it is too early > The implementation of new legislation in August 2006 required to detect a trend. accredited rail operators (metro, regional & tourist and heritage) to report details of all rail safety accidents, incidents and No injuries to passengers or staff resulted from the eight train-to- notifiable circumstances to PTSV. This requirement also resulted train collisions reported in 2007-08. The two collisions of passenger in increased reporting. A broadening of the definition of serious trains resulted in mirror damage. The remaining six collisions were injury, from 1 August 2006 to 29 February 2008, accounts for the during shunting and track maintenance operations. significant increase in numbers reported. SPADs have reduced over the January to June 2008 period and the > The Data Collection Quality Project (DCQP) is a cooperative project number of running line collisions (see definitions in appendix 2) with industry aimed at improving the quality and quantity of have increased due to minor platform scrapes. occurrence data. As a result of this initiative there has been and will continue to be an increase in the number of reports received Total intrastate heavy rail – by PTSV. This improved reporting regime will result in increased patronage data numbers of occurrences reported.

Commentary 2005-06 2006-07 2007-08 Fifteen fatalities occurred on the heavy rail network over the Total intrastate 165,842,000 187,444,000 212,209,000 2007-08 financial year. This is less than the previous financial heavy rail boardings year (22) and slightly below the five-year average of 15.2. Of growth (%) 8.6% 13.0% 13.2% the total fatalities, six were trespassers and nine were members of the public. There were no passenger fatalities over 2007-08. Sources: This compares to 12 in the previous financial year and the five-year Metro heavy rail: Official Patronage Series - Metropolitan Patronage - June 2008 average of 3.2. edition - valid to 30 November 2008 - final version - issued 20080828 Regional passenger heavy rail: Department of Transport, Public Transport Division The number of fatalities resulting from collisions with road vehicles Given the increase in rail services and road traffic, an increase in at level crossings was half (7) of the number recorded for the the overall number of rail safety occurrences is not unexpected. In previous financial year (14). The result is also trending towards the recent years annual patronage growth has exceeded approximately five-year average of 6.6 fatalities. The number of fatalities from level 13 percent per annum on the Victorian rail system. crossing collisions with a person (4) was the same as the previous financial year and below the 3.6 five-year average. There were 14 incidents that resulted in a fatality over the 2007-08 financial year. The five-year average is 12.4. Victorian tram safety statistics

2003-04 2004-05 2005-06 2006-07 2007-08 5yr average Fatalities 2 2 1 0 0 1 Serious injuries 44 48 9 59 81 48 Running line derailment 58 67 41 29 35 46 Tram-tram collision 18 20 28 21 35 24

There were no passenger tram fatalities for the 2007-08 financial An increase in metropolitan tram service provision is expected to year. The last fatality of a member of the public as a result of a tram have contributed to the slight increases in running line derailments incident was in 2005. and tram collisions. One serious injury was reported as a result of Counts of tram serious injuries have declined since January 2005, tram derailments. This derailment occurred following a collision with except for the significant increases observed in 2007 that were the a motor vehicle. Of the 35 tram collisions, one resulted in serious result of the expanded definition. An initiative implemented by the injuries. It is also important to note that many of the collisions are metropolitan tram operator aimed at reducing slips, trips and falls is with tram mirrors and are therefore of a minor nature. expected to have contributed to a reduction in serious injuries.

There were no passenger tram fatalities for the 2007-08 financial year. The last fatality of a member of the public as a result of a tram incident was in 2005.

25 Bus Bus

27 Bus audit and compliance activities for 2007-08

The following table provides an overview of the bus audit and compliance activities undertaken by PTSV’s bus auditors over 2007-08 compared to 2006-07. During 2007-08 there was an increase in the number of new accreditations approved, renewed accreditations and number of bus mechanical inspections undertaken. The number of compliance audits was lower than the previous financial year however, there was an increase in the number of Critical Defect Notices issued by PTSV. Three new auditors joined PTSV in October 2007 and had to undergo an extensive training period before they could undertake compliance audits. This training was completed in April 2008 and they commenced auditing in May 2008.

Bus audit and 2006-07 2007-08 compliance activities Bus mechanical inspections 52 73 Compliance audits 961 630 New accreditations 60 86 Critical Defect Notices issued 16 26 Renewed accreditations 80 92

Increased bus safety compliance officers in the regions New bus safety compliance officers replaced long-serving employees who retired from the Northern and Eastern Metropolitan regions and a third new position was filled for the growing regional bus services in the Ballarat region.

Maintenance Management System Early in 2007 a review of the Maintenance Management System (MMS) was conducted in response to an agreement with the bus industry. The review found that the MMS had improved the standard of bus maintenance in Victoria, however the review identified the maintenance system needed updating to meet the requirements of a modern fleet of buses. In 2008 PTSV commissioned a consultant with experience in heavy vehicle industry to update the MMS in light of the review’s recommendations. The consultant held discussions with relevant industry stakeholders to ascertain their views on relevant issues. As a result of the discussions and in consultation with PTSV the consultant developed guidelines and a framework for the updated MMS. The guidelines and framework supporting the updated MMS included: > documentation covering the roadworthy, regulation and Australian Design Rules with which buses must comply > documentation supporting the Daily Inspection, Defect Reporting System and Vehicle Safety Inspection > material for inclusion in the updated Help Kit > competencies for bus maintenance personnel. For already accredited bus operators there are a number of differences from the existing MMS. In particular, greater emphasis is placed on the daily safety check and scheduled maintenance. There is also a requirement for accredited persons who do not have access to manufacturer’s specifications to document how they plan to manage, conduct and record all inspection, maintenance and repair tasks on their buses. The MMS must also include the details of the persons accountable for the inspection and maintenance of all buses used by the company and/or operator. Licensed Bus Testers

Electronic reporting by Licensed Bus Testers (LBTs) In May 2000 the Public Competition Regulations 1999 were enacted, transferring the responsibility for monitoring the results of the annual bus inspection to PTSV. As bus inspections are a paper-based process, scrutiny of the data has never been fully undertaken. There are 25 LBTs operating in Victoria with four major testing facilities carrying out more than 90 percent of all inspections. There is an average of 7,500 annual bus inspections per year. LBTs are required to supply PTSV with a summary of the results/ outcome of each bus inspection. Over a 12-month period PTSV receives a record of every bus that is inspected in Victoria. However, the data currently supplied is minimal and insufficient for PTSV to conduct the safety trend analysis. PTSV has worked with the LBTs and VicRoads to develop an electronic reporting system (ERS) for the recording and reporting of bus inspections. The pilot ERS program was successfully completed in July/August 2008, with the system to be rolled out to the four major LBTs who conduct the majority of bus inspections. The remaining LBTs will have the option of adopting the electronic system or using a paper- based system and forwarding copies to PTSV. The data collected will assist PTSV in determining whether there are any adverse safety trends in the Victorian bus fleet. Examples of such trends could be: > buses that have a higher than average occurrence of a defect that could impact safety > operators who have a track record of using the inspection as a way of detecting defects, rather than the preferred approach of regular bus maintenance > operators who demonstrate consistently poor maintenance practices. The ERS will also provide PTSV with a record of total kilometres travelled by all buses operated by accredited bus operators. This information will allow PTSV to develop benchmarks such as incidents per kilometres travelled for the Victorian bus fleet. The data will also assist PTSV in developing and implementing a risk-based audit program of bus operators. It is intended to introduce the ERS to the LBTs in late 2008.

29 New guideline on LBTs and independence However, rather than make this mandatory, it will be located in Accredited operators are required by legislation to ensure the guidance or a code of practice. A system, as is required of rail and buses they operate are inspected at least every 12 months by an bus operators in , is not expected. independent LBT. > A more modern array of compliance and enforcement PTSV often experiences difficulty in identifying when an LBT is truly powers to enable appropriate responses to be made to independent of the bus operator for which he or she undertakes diverse situations. inspections. To help bus operators decide whether the LBT they The Director, Public Transport Safety would consult with industry are using is independent PTSV has developed the Accredited Bus in developing a compliance policy, which will describe how the Operator Guideline – Annual Inspection by an Independent Licensed powers are to be used. Bus Tester. The guideline was launched in March 2008. > A review of the definition of bus that is out of alignment LBT Workshop with the Australian Design Rules (ADRs) and most Australian jurisdictions. PTSV and VicRoads co-hosted the annual LBT Workshop in March It is proposed to link the definition to the ADRs (including 9+ 2008. The workshop included a training session conducted by seating capacity). This will capture smaller buses. In addition, VicRoads into the new Roadworthy Testing Management System it will include buses with seats stripped out, and exclude Procedures. PTSV also demonstrated the Electronic Reporting limousines. The variety of vehicles and services is increasing, so System it had developed for LBTs. it will be necessary to allow for some buses to be opted out of the Bus Operator Help Kit definition (such as high occupancy taxis) and perhaps for some vehicles/services to be opted in. During 2008 PTSV updated the Bus Operator Help Kit. The Help Kit had not been updated since the original version was developed in 2000 when accreditation was introduced. The new version updates the references and information that has been superseded since 2000. The changes do not introduce any new standards or conditions. The review of the Help Kit has also given PTSV the opportunity to reformat the MMS forms and simplify the Help Kit to make it more user friendly for bus operators and prospective bus operators. The updated Help Kit will assist those new to the industry to comprehend and meet the standards and conditions of accreditation. Bus safety legislation There are 25 LBTs operating in In April 2008, the Minister for Public Transport released a discussion paper entitled Improving Bus Safety in Victoria. The paper aims to Victoria with four major testing develop policy and legal frameworks that will enable industry adapt to changing circumstances and enable the regulator to appropriately facilities carrying out more than address the range of safety issues that arise. 90% of all inspections. There is The discussion paper analysed the safety performance of the industry and safety regulation models and concluded by seeking an average of 7,500 annual bus comment on a series of reform proposals. The following is a summary of what was proposed: inspections per year. > The accreditation scheme should be retained, but in a much improved form. The scheme needs to have a clear safety focus, and to protect the public and the industry from the entry of clearly unsuitable persons. To simplify the process, ordinary business skills criteria are not likely to be included. It was proposed that non-commercial services are no longer to be accredited, however many courtesy services can be regarded as commercial in nature. > The accreditation scheme should include safety duties. These will be similar to duties imposed under modern safety legislation, including the RSA and the Occupational Health and Safety Act 2004. The operator will continue to be primarily responsible for operational safety, but duties will also be imposed on persons in the bus safety ‘chain of responsibility’ people such as drivers and maintenance contractors are fundamental to bus safety. A risk management approach to achieving safety will also be expected. Key bus issues 2007-08 Random audits PTSV Officers conducted an audit of all buses visiting the bus Runaway buses parking areas at Phillip Island (8 February 2008), the Twelve In late 2008 there were two incidents where bus drivers vacated Apostles on the Great Ocean Road (9 February 2008) and at the their buses without making the bus safe (applying the park Australian Grand Prix (17 March 2008). These audits sought to brake and disengaging the transmission). In one incident, the identify unaccredited operations and whether accredited operators driver sustained injuries and in both incidents there was damage were operating outside their category of accreditation or operating to property. buses with mechanical defects. Bus door safety and runaway buses are a significant safety issue Of the buses audited: for all bus operators, particularly for route bus operators where the > 19 percent were not displaying No Smoking signs or driver relies on the door-brake interlock system to keep the bus accreditation numbers stationary while picking up or dropping off passengers. > 10 percent had major visible mechanical defects PTSV has raised this issue with VicRoads, the Australian Public > 8 percent had minor visible mechanical defects. Transport Group (APTG) and the former Department All these matters were subsequently followed up by PTSV of Transport and Regional Services (DOTARS), requesting the ADRs with the applicable operators. include a requirement for all buses to be fitted with anti-runaway devices. This issue has been accepted by DOTARS and will be included in the review of the ADR58.

31 Moving bus safety regulation into the 21st Century It also includes a review of all bus investigation reports with a view to developing an understanding of issues such as time periods As Victoria’s demand for safe reliable public transport when catastrophic bus incidents are likely to occur, the root continues to increase, so does the need for effective and causes of such incidents, any geographical factors, the types of efficient transport safety legislation. buses and bus operators involved in such incidents, the likely While bus travel is one of the safest forms of transport in Victoria, transport routes and other significant variables. current bus safety legislation and its regulation is outdated and no longer appropriate for the safety risks faced by bus operators. > Stage two will be a risk workshop involving bus safety staff and subject mater experts that applies a sanity check to the data In April 2008 the Department of Transport released a discussion and information provided in stage one. paper for public comment that canvassed revised bus safety regulation. This generated considerable interest from stakeholders, > Stage three is the development of a risk register that can not least of which was PTSV which, as the safety regulator, will be updated as new information becomes available. have responsibility for assuring bus operators implement and > Stage four will use the risk register and the analysis undertaken maintain the new safety requirements. in earlier stages to construct a generic Management Oversight To prepare for this new regulation, PTSV has initiated two and Risk Tree (MORT) that will then be available for updating as complementary projects – one that will identify and put in place PTSV’s bus safety risk information matures. new bus safety operational policies and safety audit procedures, > Stage five will identify the key bus safety performance guidance materials and resources and one that will develop a risk- indicators that PTSV’s bus safety team will then use to shape based bus safety audit program. While the former project is very its annual safety audit program. The key performance indicators much dependent on when the new bus safety legislation is passed will be lead and lag indicators that will be updated at regular by Parliament, the latter project was commenced in June and is intervals as PTSV reviews bus safety performance across expected to provide results later in 2008. Victoria’s bus industry. The bus safety risk-based audit project is being conducted Information on each stage of the bus safety risk-based audit in five stages. project will be published on PTSV’s website www.ptsv.vic.gov.au > Stage one consists of a worldwide literature search as each stage is completed. on catastrophic bus incidents, analysis of this data and correlation with Victorian bus incident data.

As Victoria’s demand for safe reliable public transport continues to increase, so does the need for effective and efficient transport safety legislation. Victorian bus safety statistics

2003-04 2004-05 2005-06 2006-07 2007-08 5yr average

Fatalities 3 5 5 4 2 4 Selected bus-related fatalities Accident near bus 0 1 0 1 0 0 Bus 0 0 0 0 0 0 Car 0 1 3 2 0 1 Cyclist 1 1 0 0 0 0 Pedestrian 2 2 2 1 1 2 Train-tram 0 0 0 0 0 0 Truck 0 0 0 0 0 0 Bus passenger fatalities 0 0 0 1 0 0

Bus-related serious injuries

2003-04 2004-05 2005-06 2006-07 2007-08 5yr average Serious injuries 54 81 54 60 54 61 Selected bus-related serious injuries Accident near bus 2 1 1 1 2 1 Bus 0 0 0 0 0 0 Car 7 41 7 14 19 18 Cyclist 2 2 0 1 4 2 Pedestrian 3 8 5 9 6 6 Train-tram 7 7 0 0 0 3 Truck 0 6 4 0 3 3 Bus passenger serious injuries 35 45 38 36 30 37

There were no bus passenger fatalities during 2007-08. The number of bus passenger serious injuries remained stable. The slightly larger counts for 2005 were due to an increase in the number of bus collisions with cars. The majority of bus-related fatalities are the result of collisions with cars or pedestrians. Since the high recorded in 2004-05 and 2005-06, bus-related fatalities have continued to be low. Since 2004-05 bus-related serious injuries have continued to be significantly lower. As noted previously, collisions with cars can result in multiple serious injuries. The majority of bus collision types are equal to or below the five- year average. Considering the ongoing increase in road traffic, the Considering the ongoing lower counts of bus to car collisions is a good result. Bus patronage has grown by 7.4 percent* for each of the past two financial years increase in road traffic, the meaning that bus safety continues to improve. *Source: lower counts of bus to car Metro bus: Official Patronage Series - Metropolitan Patronage - June 2008 edition - valid to 30 November 2008 - final version - issued 20080828 collisions is a good result.

33 Enhancing perfomance Human Factors Seminar Series Rail Resource Management The PTSV Human Factors Seminar Series provides an introduction The Rail Resource Management (RRM) guidelines and training to human factors, its application in public transport and raises materials were delivered and launched in December 2007. RRM type awareness of its importance in the rail and bus industries. A range training by Australian rail operators is voluntary. The RRM materials of seminars will be delivered each year, focusing on human factors have been developed to assist organisations in the development of issues relevant to the safety of public transport operations. resource management type training. The first in the series was delivered on 26 June 2008 with a PTSV, jointly with the New South Wales Independent Transport Safety presentation by Professor Ian Johnston of Monash University and Reliability Regulator (ITSRR), has worked with the Australasian Accident Research Centre titled Human Factors – neither magic Railways Association (ARA) and rail industry stakeholders on this nor rocket science. The seminar provided a broad introduction to national project. It is endorsed by the RSRP. human factors including discussions around how risk perception, The RRM Guidelines and further information is available through community values and institutional behaviour contribute to the PTSV, ITSRR or RSRP websites. Template training materials are system safety. also available free of charge for accredited rail operators in Australia Approximately 60 representatives from the rail industry, and New Zealand. These can be obtained by contacting PTSV or government bodies and human factors consultancies attended, ITSRR directly. as did many PTSV staff. The RRM project has moved into its final stages with the conduct of The seminar was well received with feedback forms indicating a pilot project to trial the materials and to document lessons learned 83 percent of attendees found the topics beneficial and all indicating from this first implementation. V/Line is running the RRM Pilot and they would attend future seminars. allow the RRM Project to gather information regarding the pitfalls Attendee comments on the seminar included ‘good insight into this and lessons of implementation. interesting topic’ and ‘topics covered were fascinating, relevant’. Targeted education and enforcement pilot program Other comments noted the seminar explored ‘a different mindset’ PTSV partnered with Victoria Police, Australasian Railway and that the most beneficial part was ‘re-thinking my attitude Association, VicRoads, and community RoadSafe councils at to safety’. Colac, Central Highlands and Inner Eastern to deliver a pilot Contributing Factors Framework project to encourage better compliance with road rules applying The Contributing Factors Framework (CFF) will provide rail safety to level crossings. investigators, accredited rail operators and regulators with a The project was managed on behalf of the National Railway nationally consistent, structured framework and process to record Level Crossing Behavioural Coordination Group reporting through and analyse the contributing factors identified during the systemic to Standing Committee of Transport - Rail Group. investigation of rail safety occurrences. The CFF is complementary The pilot set out to determine whether research into behavioural to and enhances current occurrence reporting processes. change at railway level crossings was feasible with available CFF’s benefits include: resources, whether it was likely effective enforcement interventions > The potential to compare contributing factors across participating could be developed and how education and enforcement could be organisations and/or jurisdictions. made to work together in this context. > Over time, aggregate CFF data will permit the identification and Parliamentary Road Safety Committee – analysis of safety trends. inquiry into improving safety at level crossings > Providing a more informed understanding of the systemic issues In July 2007, the Parliamentary Road Safety Committee was tasked associated with rail safety occurrences and enhancing the to inquire into existing, new and developing technology, with the aim identification of more sustainable solutions. of improving level crossing safety. > Encouraging improvement to systemic investigation skills. PTSV submitted its response to the Committee in October 2007 Following road-testing and consultation with rail industry and was subsequently invited to present to them. PTSV’s submission stakeholders, the Rail Safety Regulators’ Panel (RSRP) approved the outlined the importance of considering low-cost warning devices CFF for publication. Use of the coding framework by rail industry as additional protection at passive crossings, providing the devices stakeholders is voluntary, however, the Regulators will be using the were highly reliable and appropriately modified human behaviour. coding framework on the investigations they conduct or receive The implementation of new warning devices at these passive from their accredited rail operators. The CFF will be launched crossings should offer additional protection against a possible nationally in February 2009. Documentation will be available online catastrophic event between a heavy vehicle and passenger train, or by contacting PTSV directly. which is considered to be the rail industry’s greatest risk. PTSV also presented to the Road Safety Committee Forum into fail-safe technologies at level crossings from a legal and technical perspective. The Parliamentary Committee was expected to report on the outcome of the inquiry by late 2008.

35 Outlook Outlook

37

PTSV’s outlook for 2008-09

Rail compliance PTSV’s focus for 2008-09 is to raise the level of industry compliance with the RSA. This has commenced with the reaccreditation of all the commercial rail operators by 30 June 2008 and the tourist and heritage operators will follow by 30 June 2009. In addition to this, a new Rail Safety Compliance Program has been designed. This program of audit, compliance inspections and investigation is risk based rather than carrying out our regulatory interventions on an annual basis. The focus of these interventions will result in a deeper level of engagement than management system audits alone.

Federal Government initiatives During 2008 the Federal Government announced that due to industry economic concerns that it would like to see a national system of rail safety regulation in place. PTSV will work with the National Transport Commission (NTC) in evaluating possible systems and other options to achieve the same effect. PTSV will provide data and information to the NTC who are conducting a Regulatory Impact Statement to determine if there is a case for a national system.

Safety at level crossings PTSV awaits the report from the Parliamentary Road Safety Committee on new technologies for level crossings, and looks forward to supporting the recommendations from this work. Another significant program of work that will be starting for level crossings is the development of safety interface agreements (SIA). Following an amendment to the RSA, this work involves the development of agreements about the management of safety risks arising at railway interfaces. This requires a rail infrastructure manager and road manager to identify and assess safety risks arising from rail interfaces, namely railway crossings. The relevant parties are then required to reach agreement on how to manage those risks. This legislation requires parties to enter into SIAs by 1 July 2010.

Metropolitan refranchising of train and tram operators Through the refranchising process, PTSV will work with the successful bidder to determine it has the competency and capacity to meet Victoria’s rail accreditation requirements under the RSA. This process will conclude with heavy and light rail operations commencing in November 2009.

National standards on positive safety cultures PTSV is looking forward to seeing the result from the Rail Industry Safety and Standards Board’s (RISSB) work on national standards as well as an annually refreshed safety improvement strategy for During 2008 the Federal its members. This would align RISSB with other peak bodies across the world in developing such a strategy and would bring industry Government announced that many benefits. PTSV still believes accredited rail operators must continue their due to industry economic efforts to develop positive safety cultures and embrace human concerns that it would like to factors approaches to the way they deliver their services. The RISSB product on safety culture auditing that has recently been purchased see a national system of rail by RISSB will be an excellent start and PTSV looks forward to seeing the Victorian AROs implementing the system. safety regulation in place.

39 Appendices Appendices

41 Appendix 1 Bus safety legislation New safety legislation is being developed to take account of the Progress against 2007-08 outlook expanding and changing nature of Victoria’s bus industry. Managing catastrophic risk potential Key features of the new bus safety legislation include: Main elements of the catastrophic risk model have been > Retaining bus operator accreditation, in a modernised form, but developed and are being used by PTSV. In 2007-08 risk-based limiting this requirement to commercial bus services. targeted compliance inspections were informed by the catastrophic > Reinforcing safety regulation with outcome-based safety duties risk model. covering all persons in the ‘chain of responsibility’ who can Improving the quality of investigations conducted influence safety (including persons who drive and maintain by rail operators vehicles and persons who decide on the location and design of bus stops). Safety duties will apply to all bus services, commercial PTSV will be supporting the roll-out of the national Contributing and non-commercial. Factors Framework that has now been developed and will be launched in February 2009. PTSV recently used this tool to look > Redefining ‘bus’ to include all buses with more than nine into metropolitan rail incidents. passenger seats.

Train driver route knowledge > Improving regulator powers to deal appropriately with safety breaches. A compliance inspection into an incident that occurred on the Geelong Grain Loop Access in 2007 looked into driver route Once the new bus legislation is enacted a similar risk-based knowledge. In this particular example it was evident there approach will be put in place. In the meantime, PTSV will be looking was a need for standards to be developed to ensure there for compliance with the new bus maintenance management system was a consistent understanding by all operators of the driver and the electronic reporting system for Licensed Bus Testers. competencies and the associated safety implications of operating The new Bill is planned to be considered by the Victorian Parliament in a multi-operator environment. in late 2008 with a view to passage in early 2009. The new law is expected to take effect in 2010. PTSV will provide regulatory Achieving excellence in inspection and maintenance guidance to the bus industry once the details of the new safety law During 2007-08 PTSV closely monitored rail safety maintenance and are finalised by Parliament. the implementation of improvements in the rail network, particularly the metropolitan network. This has been conducted through the re-accreditation process as well as the development of the Rail Safety Compliance Program. PTSV has now formalised its plans to carry out further reviews and has established, in partnership with the rail industry, a project to look at long-term asset safety over 2008-09 and 2009-10.

During 2007-08 PTSV closely monitored rail safety maintenance and the implementation of improvements in the rail network, particularly the metropolitan network. Appendix 2 Heavy rail safety statistics

Victorian heavy rail incident statistics July 2003 – June 2008 Please note that the term ‘heavy rail’ excludes trams. The following statistics are broken down into six monthly periods. July- Jan- July- Jan- July- Jan- July- Jan- July- Jan- Dec 03 June 04 Dec 04 June 05 Dec 05 June 06 Dec 06 June 07 Dec 07 June 08 Fatalities 6 7 5 5 9 7 7 15 4 11 Fatal incidents 6 7 3 5 9 6 7 5 4 10 Serious injuries 17 7 2 12 40 35 77 88 70 55 Passenger fatalities 0 2 0 0 0 2 1 11 0 0 Passenger 13 6 1 5 23 13 57 59 51 42 serious injuries Fatalities at level 0 1 3 2 3 3 3 11 2 5 crossings (collision with road vehicle) Fatalities at level 2 1 1 2 2 3 1 2 1 3 crossings (collision with person) Level crossings 24 27 29 15 23 27 31 41 57 50 (near miss with person) Level crossings 36 37 51 61 60 69 92 94 63 100 (near miss with road vehicle) Running line 8 14 9 15 8 7 14 7 13 9 derailment Running line 27 21 28 29 45 34 33 33 38 55 collision Running line 2 1 0 1 2 2 0 1 4 4 train-train collision Signals passed at 113 93 75 74 76 79 76 93 124 73 danger (SPAD)

Definitions – heavy rail Level crossing collision only includes collision with person and Fatality includes the death of employee, passenger, trespasser, or road vehicle at a level crossing. member of the public (excluding suicides and natural causes). Signal passed at danger is where a train passes, without authority, Serious injury of an employee, passenger, trespasser, or member a signal displaying a stop indication or stop aspect. Includes human of the public (excluding suicides and natural causes). From 1 August error SPADS (driver misjudged, completely missed while running 2006 to 29 February 2008 the definition of serious injury was and starting against signal) and signal restored as train approached. broadened, which resulted in increased counts. Fatal incident is an incident where at least one fatality (excluding Running line collision includes collision with train, rollingstock, suicides and natural causes) has occurred. people, infrastructure and road vehicle. Excludes level crossing Normalising collision, collision with animal, obstruction, missile (e.g. object The above counts are not normalised so the increase in rail thrown at train). patronage is not taken into account by these numbers.

43 Appendix 3 Tram safety statistics

Victorian tram safety incident statistics July 2003 – June 2008 The following statistics are broken down into six monthly periods. July- Jan- July- Jan- July- Jan- July- Jan- July- Jan- Dec 03 June 04 Dec 04 June 05 Dec 05 June 06 Dec 06 June 07 Dec 07 June 08 Fatalities 1 1 1 1 1 0 0 0 0 0 Serious injuries 30 14 30 18 4 5 8 51 63 18 Running line 30 28 24 43 27 14 18 11 16 19 derailment Tram-tram collision 9 9 9 11 18 10 9 12 13 22

Definitions - tram Normalising Fatality includes the death of an employee, passenger, trespasser, The above counts are not normalised so the increase in rail or member of the public (excluding suicides and natural causes). patronage is not taken into account by these numbers. Serious injury includes the serious injury of an employee, passenger, trespasser, or member of the public (excluding suicides and natural causes). From 1 August 2006 to 29 February 2008 the definition of serious injury was broadened, which resulted in increased counts. Running line derailment is any derailment occurring in the movement of a tram on a running line. Tram-tram collision is any running line collision between two or more trams (excludes level crossing collisions). Appendix 4 Bus safety statistics

As a condition of accreditation, bus operators are required to advise PTSV of any bus safety incidents that occur when operating across Victoria.

Bus passenger fatalities July 2003 – June 2008 The following statistics are broken down into six monthly periods. July- Jan- July- Jan- July- Jan- July- Jan- July- Jan- Dec 03 June 04 Dec 04 June 05 Dec 05 June 06 Dec 06 June 07 Dec 07 June 08 Fatalities 0 0 0 0 0 0 0 1 0 0

Bus passenger serious injuries July 2003 – June 2008 The following statistics are broken down into six monthly periods. July- Jan- July- Jan- July- Jan- July- Jan- July- Jan- Dec 03 June 04 Dec 04 June 05 Dec 05 June 06 Dec 06 June 07 Dec 07 June 08 Serious injuries 11 24 10 35 34 4 11 25 18 12

Bus-related fatalities July 2003 – June 2008 The following statistics are broken down into six monthly periods. July- Jan- July- Jan- July- Jan- July- Jan- July- Jan- Dec 03 June 04 Dec 04 June 05 Dec 05 June 06 Dec 06 June 07 Dec 07 June 08 Accident near bus 0 0 1 0 0 0 0 1 0 0 Bus 0 0 0 0 0 0 0 0 0 0 Car 0 0 1 0 3 0 0 2 0 0 Cyclist 0 1 1 0 0 0 0 0 0 0 Pedestrian 1 1 2 0 1 1 1 0 0 1 Train-tram 0 0 0 0 0 0 0 0 0 0 Truck 0 0 0 0 0 0 0 0 0 0

45 Appendix 5 Significant train/tram/bus incidents

Date Location Description 29/6/2007 Werribee Following an incident on 27 June, PTSV was notified by the Australian distributor for an imported LED signal aspect that a wrong side failure of that model had occurred. On investigation the failure mechanism involved a loss of sealing against water entry due to mechanical damage to the lense with subsequent corrosion of the printed circuit board leading to permanent illumination of the green aspect. Both affected AROs have instituted either additional operational restrictions or inspections of signals to manage the risk. The Australian distributor is developing a longer term solution in conjunction with the overseas manufacturer. 22/08/2007 Somerville Level crossing collision between a passenger train and a truck. 29/08/2007 Hume Highway South Centre, Express coach ran into the back of a ‘B’ double truck and trailer Glenrowan (Bus) combination on the Hume Highway near Glenrowan. 24/9/2007 Corner St Kilda Road and Tram-tram collision. Armadale Street, Melbourne 16/10/2007 Corner St Kilda & City Roads, Melbourne Tram-tram collision. 23/10/2007 Corner Flemington & Racecourse Roads, Parkville Tram-tram collision. 09/12/2007 Seymour Child (trespasser) struck and killed at Strathmore platform. 16/12/2007 Southern Cross Station Wrong side failure. 28/01/2008 Tyabb Level crossing collision between a passenger train and a car. 31/01/2008 Tandarra Level crossing collision between a passenger train and a car. 25/02/2008 Mitiamo Level crossing collision between a freight train and a car. 24/03/2008 Buckley Level crossing collision between a passenger train and a four wheel drive. 30/03/2008 Vite Vite Fiery Creek Block Point A train derailed 12 wagons. Appendix 6 Output performance measures

Public Transport Safety and Regulation Unit of Frequency 2007-08 target Actual measure Quantity > Train and tram safety compliance inspections (unannounced percent Quarterly 100 100 audits) undertaken where an Improvement Notice or non conformance/compliance is issued at an audit. > Bus safety mechanical inspections. number Quarterly 50 53 Quality Train and tram safety: > Improvement Notices addressed within agreed timeframes. percent Quarterly 100 100 > Audit non conformance/compliance addressed within agreed percent Quarterly 100 100 timeframes. > Application for a material change (to a safety management percent Bi-annual 100 na system of an accredited rail organisation) reviewed within 30 days1. Bus safety: > Audit non conformance/ compliance addressed within percent Quarterly 100 100 agreed timeframes. Timeliness Train and tram safety: > All accredited organisations audited annually2. percent Quarterly 100 100 Bus safety: > All accredited organisations audited every two years. percent Quarterly 50 50

Appendix 7 Freedom of Information

PTSV has established its own Freedom of Information (FOI) Officer The change has taken place after a review of the Safety Director’s within its Regulatory Policy & Legal group. The PTSV FOI Officer status under the FOI Act. directly receives and processes requests for access to documents Where a request relates to documents that may be relevant to both made under the Freedom of Information Act 1982 which relate to PTSV and DOT, the PTSV FOI Officer works with the applicant and documents in PTSV’s possession. Previously these were handled by the DOT FOI Unit to determine the most efficient and appropriate the central DOT FOI Unit. way of handling the request. There were 24 applications made under the FOI Act relevant to PTSV. Of those, 13 were from Members of Parliament, with the remaining 11 from the media. Almost all requests were for access to data held by PTSV.

1 The Rail Safety Act 2006 does not mandate a time limit on PTSV’s consideration of an application for a material change to a safety management system of an accredited rail organisation. The target of 30 days is an internal PTSV performance indicator. 2 Effective from December 2007, the requirement for PTSV to conduct an annual safety audit of accredited rail operators was removed from the Rail Safety Act 2006. 47 Appendix 8 Appendix 9 Complaints and enquiries Analysis of PTSV’s website

In late 2007, PTSV introduced a complaint handling policy and PTSV launched its own website separate from the Department procedure to assist PTSV staff to handle complaints in a manner of Transport in October 2007. The PTSV website was developed consistent with Australian Standards and the Ombudsman Victoria’s to provide operators with a wide range of key safety information Guide to Complaint Handling for Victorian Public Sector Agencies. to assist them in their operations as well as provide information Through this process PTSV now also captures and reports on all to promote the continuous improvement of public transport enquiries received through its website. safety in Victoria. Over the period 23 October 2007 to 30 June 2008 PTSV dealt Over this time awareness of the website has steadily increased with 26 complaints: and website statistics have shown consistent usage. The following graphs show that over the nine-month period the number of visitors > Bus operators/safety - 9 to the website was consistent and gradually increasing, while the > Rail operators/safety - 15 number of page views increased and then decreased. This could > Directed at PTSV - 2 be due to a number of reasons, including visitors to the website now being able to move around the site more efficiently, therefore Over the same period PTSV dealt with 126 enquiries. visiting less pages to get the information they require. The top five categories of enquiries were: One of PTSV’s ongoing projects following the development of the > Requests for PTSV publications/feedback on website for 2008-09 is to undertake a full evaluation of the current PTSV publications - 25 website to ensure it is providing the level of service sought by users. > Rail safety worker competency, health and fitness - 19 PTSVPTSV website website analysis analysis > Level crossing safety - 11 > Information on bus operator accreditation - 9 9000 8000 > Rail safety legislation and standards - 9 7000

PTSVPTSV complaintscomplaints andand enquiries enquiries 6000 5000 25 4000 ■ complaints ■ enquiries (total 26) (total 126) 3000 2000 20 1000

0

15 Oct-07 Apr-08 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 May-08 Jun-08

Key Visitors 10 Page views

5 Appendix 10 Risk attestation

0 I, Alan Osborne, certify that Public Transport Safety Victoria (PTSV) has risk management processes in place broadly consistent with the Australian/New Zealand Risk Management Standard. PTSV is committed to continuously improving its risk processes Directed at PTSV PTSV publications health & fitness and is currently reviewing its internal control system to enable the Bus operators/safetyRail operators/safety Level crossing safety PTSV executive to understand, manage and satisfactorily control Bus operator accreditation risk exposures. Rail safety worker competency, Rail safety legislation & standards In addition, PTSV’s risk profile has been critically reviewed within the last 12 months. This attestation has been subject to external verification. Data sources for industry statistics Heavy rail, tram and bus statistics – PTSV Occurrence Database, data as reported to PTSV from Accredited Operators.

If you would like to receive this publication in an accessible format, please telephone 9655 2050, or email [email protected]. This publication is also published in PDF on www.ptsv.vic.gov.au. Published by Public Transport Safety Victoria Level 8, 121 Exhibition Street, Melbourne, Victoria 3000 Telephone (03) 9655 8949. November 2008. Copyright State Government of Victoria 2008. This publication is copyright. No part may be reproduced by any process except in accordance with provisions of the Copyright Act 1968. Authorised by the Victorian Government, Melbourne. ISSN: 1835-4262

PTSV acknowledges Robert Wilson for kindly providing permission to reproduce heritage and regional rail images used in this publication.

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