PUBLIC TRANSPORT SAFETY
Code of Practice for Health Assessment of Rail Safety Workers
Volume 2 Assessment Procedures and Medical Criteria
Department of Infrastructure ii Department of Infrastructure Foreword
This Code of Practice for Health Assessment of Rail Safety Worker outlines the systems underpinning a rigorous approach to monitoring the health and fitness of rail safety workers. A review of existing medial examination standards was recommended in recent rail accident investigation reports, especially the report on the Footscray Station collision in 2001. The review highlighted deficiencies in the quality and/or implementation of current medical standards, including the need to clarify management responsibilities and systems. The review found that the standards had not kept abreast of advances in medical knowledge, especially the need to screen for conditions which can affect vigilance in Safety Critical Workers. In addition, the standards needed to be brought up to date with contemporary Anti-discrimination and Privacy Laws. These considerations are reflected in the Code of Practice bringing standards and systems up to date. Most importantly, the new system contained in this Code of Practice is based firmly on the foundations of a risk management approach. This greatly improves the power of assessments to identify and manage the health and fitness of rail safety workers according to risk. Practical guidance and examples for implementing the risk-based approach are provided in a Guideline for Health Risk Management. The new health assessment system is the result of extensive consultation with industry stakeholders and health professionals In September 2003 the National Road Transport Commission (NRTC) adopted the Victorian draft Code as the basis for developing a National Standard for Health Assessment of Rail Safety Workers as part of its Work Program approved by the Australian Transport Council of Ministers. The National Standard is intended for adoption in 2004 and processes will be put in place to ensure that consistency between the National Standard and this Code of Practice is maintained. Release of this Code of Practice demonstrates the Victorian Government’s commitment to building public confidence that risks to public safety are properly controlled and that wherever practicable, railway safety is continuously improved in line with society’s expectations and contemporary, technical knowledge.
Graham Edkins Director Public Transport Safety December 2003
Code of Practice for Health Assessment of Rail Safety Workers iii iv Department of Infrastructure
CONTENTS
PART 1: ASSESSMENT REQUIREMENTS AND PROCEDURES...... 1 1. Overview of Code of Practice...... 1 2. Authorisation of Health Professionals Conducting Health Assessments of Rail Safety Workers...... 2 3. Privacy Laws...... 3 4. Responsibilities and Relationships...... 5 5. Workers Who Require a Health Assessment...... 7 6. Matching the Level of Health Assessment to Risk Category ...... 9 7. Types of Health Assessments Required ...... 11 8. Procedures for Conducting Health Assessments ...... 15 9. Fitness for Duty Classifications...... 18 10. Record Keeping ...... 20 11. Communicating with the Worker’s General Practitioner and other Health Professionals...... 20
PART 2: MEDICAL CRITERIA ...... 23
PART 2A: MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS...... 24 1. ALCOHOL...... 24 2. ANAESTHESIA...... 27 3. CANCER...... 28 4. CARDIOVASCULAR DISEASES...... 29 5. DIABETES ...... 39 6. DRUGS – ILLICIT ...... 42 7. DRUGS – PRESCRIPTION AND OVER THE COUNTER (OTC) ...... 45 8. EPILEPSY...... 48 9. GASTROINTESTINAL AND HEPATIC DISORDERS...... 52 10. HEARING...... 54 11. HIV/AIDS...... 57 12. METABOLIC AND ENDOCRINE DISORDERS...... 58 13. MUSCULOSKELETAL DISORDERS...... 59 14. NEUROLOGICAL DISORDERS ...... 61 15. PREGNANCY ...... 65 16. PSYCHIATRIC DISORDERS...... 66 17. RENAL FAILURE...... 68 18. RESPIRATORY DISEASES AND SPEECH ...... 70 19. SLEEP DISORDERS ...... 72 20. SYNCOPE / BLACKOUTS...... 77 21. VESTIBULAR DISORDERS ...... 78 22. VISION AND EYE DISORDERS...... 80
Code of Practice for Health Assessment of Rail Safety Workers v PART 2B: MEDICAL CRITERIA FOR AROUND THE TRACK PERSONNEL ...... 87
PART 3: CASE STUDIES...... 91 1. Case Study 1: Train Driver on Commercial Network presenting for Periodic Health Assessment...... 92 2. Case Study 2: Train Controller presenting for Triggered Health Assessment ...... 96 3. Case Study 3: Signaller presenting for Periodic Health ...... 100 4. Case Study 4: Flagman presenting for Triggered Health Assessment ...... 103 5. Case Study 5: Tram Driver presenting for a Triggered Health Assessment ...... 107
PART 4: MODEL FORMS ...... 111
PART 5: ALCOHOL AND DRUG CONTROLS ...... 137
GLOSSARY OF TERMS...... 141
ACKNOWLEDGMENTS ...... 147
CONTACT INFORMATION ...... 148
LIST OF TABLES Table 1. Criteria for Selection of Authorised Health Professionals ...... 4 Table 2. Summary of Health Assessment Requirements for Rail Safety Workers ...... 13
LIST OF DIAGRAMS Diagram 1. Interfacing Health and Human Resources Programs...... 3 Diagram 2. Relationships in the Implementation of Health Assessments for Rail Safety Workers ...... 6 Diagram 3. Definition of Risk Categories for Rail Safety Work ...... 8 Diagram 4. Health Assessments Supporting Fitness for Rail Safety Work...... 12 Diagram 5. Conducting a Health Assessment for Fitness for Rail Safety Duties...... 21 Diagram 6. Periodic Health Assessment - Management of possible impairment due to alcohol or drugs (illicit and prescription/OTC) ...... 25 Diagram 7. Periodic Health Assessment - Management of possible impairment due to alcohol or drugs (illicit and prescription/OTC) ...... 43 Diagram 8. Drug and Alcohol Impairment Assessment and Management ...... 46 Diagram 9. Evaluation Process for Colour Vision ...... 80 Diagram 10. Periodic Health Assessment - Management of possible impairment due to alcohol or drugs (illicit and prescription/OTC) ...... 89
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PART 1: ASSESSMENT REQUIREMENTS AND PROCEDURES
1. Overview of Code of • criteria by which health professionals are Practice authorised by accredited rail organisations. 1.1 Structure Volume 2 may also be used by specialist health professionals who may be consulted This Code of Practice for Health Assessment about a worker’s health assessment, for of Rail Safety Workers comprises two example, optometrists, psychologists or volumes. occupational therapists. Volume 1: Management Systems 1.2. Purpose Volume 1 provides guidance for accredited The Code of Practice provides practical rail organisations in establishing appropriate guidance for accredited rail organisations management systems. It outlines the to meet their legal obligations under the to responsibilities of rail organisations, workers and health professionals. It also describes monitor the health and fitness of rail safety workers. systems for health risk management including approaches to risk assessment, This responsibility is an essential part of scheduling of assessments, communication, the rail safety management systems aimed records management and the appointment at minimising risks to protect the safety of: of authorised health professionals. • the public; Volume 2: Health Assessment Procedures • rail safety workers and their fellow and Medical Criteria workers; and Volume 2 outlines the procedures for • the environment. conducting health assessments and provides the medical criteria for judging fitness for duty. 1.3 Application and Scope It is a practical reference for health Volumes 1 and 2 of the Code of Practice for professionals authorised by accredited rail Health Assessment of Rail Safety Workers organisations to conduct health assessments apply to all rail organisations accredited of rail safety workers and provides: under the Transport Act 1983 to operate in • clear medical criteria for rail safety Victoria. worker capability based on available The Code is intended for use to assess the evidence and expert medical opinion; health and fitness of potential and existing • general guidelines for managing rail workers to undertake rail safety work as safety workers with respect to their defined in the Transport Act. fitness for duty; Whilst the Code does assess individual • guidance for reporting to accredited rail worker safety on and about the track, it does organisations, including model forms. not cover other occupational health and Volume 2 also summarises from Volume 1: safety matters such as occupational exposure. The employer must address • the system of health assessments such issues and integrate them with the applied by accredited rail organisations, health assessments as appropriate. • interface with other health, safety and human resources initiatives 1.4 How to use the Code • risk categorisation of rail safety tasks Volume 2 of the Code outlines the information and how the health assessment necessary for conducting health assessments requirements reflect the risks; of rail safety workers. It comprises five parts: • types and frequencies of assessments;
Code of Practice for Health Assessment of Rail Safety Workers 1 PART 1 – Health Assessment PART 4 – Model Forms Requirements and Procedures Part 4 includes the model forms that may be Part 1 summarises the management systems used in administering the health assessment for health assessments of rail safety workers system. The rail organisation will provide contained in Volume 1 of the Code (Volume 1 their own forms based on these model forms. should be referred to for details). It identifies PART 5 – Drug Controls the categories of rail safety workers to undergo assessment as well as the nature Part 5 provides an explanation of the drug and frequency of the assessments and the control provisions in the Transport Act assessments procedures. 1983. It also outlines the system of authorisation 1.5. Interfaces with other Health and for health professionals conducting health assessments and the roles and Human Resources Programs responsibilities of the employer, workers and Health assessments are one aspect of an health professional. integrated system aimed at achieving safety It is essential that authorised health on the rail network. The assessments may professionals are familiar with the content interface with a range of other health and of Part 1. human resources programs, some of which have a legislative base. PART 2 – Medical Criteria The authorised health professional will need Part 2 details the medical criteria for to have some understanding of how these assessing fitness for duty. It comprises: initiatives interface in practice. It is the • Part 2A, medical criteria for Safety Critical responsibility of the rail organisation to Workers (Categories 1 and 2); ensure the health professional is kept up to date about the organisation’s programs, • Part 2B, medical criteria for Around the policies and procedures. Track Personnel (ATTP) who work in an Uncontrolled Environment (Category 3). The interfaces with relevant programs are illustrated in Diagram 1. The medical criteria in Part 2 are presented in chapters corresponding to body system or disease categories and are arranged 2. Authorisation of Health alphabetically. Professionals Conducting The medical standards provide a core Health Assessments of assessment relevant to rail safety work. Rail Safety Workers However specific details will vary between organisations. Matters such as colour vision 2.1 Who may perform health or musculoskeletal requirements may be assessments varied appropriate to the risks assessed in an organisation, by a specialist in occupational Health assessments for rail safety work must medicine and with full documentation. be performed by a health professional who However specific questionnaires used in the has met the defined criteria. examination forms such as the Epworth A health professional who meets the defined Sleepiness Scale or K10 must not be varied. criteria may be authorised by an accredited PART 3 – Case Studies rail organisation to conduct the health assessments for rail safety work (an Part 3 contains a series of case studies that authorised health professional). help illustrate rail safety tasks, the health requirements of those tasks, the process of Safety Critical Worker Health Assessments health assessment and the subsequent must be performed by a medical practitioner. management. Track Safety Health Assessments may be performed by a nurse with suitable occupational health qualifications.
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Diagram 1. Interfacing Health and Human Resources Programs
Practical on-site tests, such as tests for 3. Privacy Laws colour vision, hearing or musculoskeletal In administering the rail safety worker health capacity, may be performed by a person assessments rail organisations and with appropriate skills and experience. examining health professionals must ensure Such a person is not required to be health they comply with the Privacy Principles trained, however the assessments should contained in privacy legislation and that be undertaken in consultation with the health records are managed and stored in examining health professional. line with the Health Records Act 2002. Privacy legislation prohibits the disclosure 2.2 Criteria for appointing an of a person’s medical, or health information authorised health professional from being disclosed to a third party without The rail organisation should ensure the the clear consent of that person. health professional meets the selection criteria provided in Table 1 as a basis for 3.1 Privacy Policy appointment. The Victorian Health Records Act 2002 The criteria focus on the health professional’s includes a requirement for organisations to knowledge and understanding of the rail have a policy to protect the privacy of health occupational environment, the risks information. This includes provision for associated with rail safety work and the ensuring workers understand: corresponding clinical tests to be applied. • the purpose for collecting and storing the health information; The rail organisation is not required to assess the health professional’s medical knowledge. • what information will be stored and where; The rail organisation may offer assistance to the health professional to meet the • the fact that he or she can access it; criteria. This can be done by providing and them 2with relevant information and/or an • to whom the information may be on site visit as well as providing a copy of disclosed. this Volume 2 of the Code of Practice.
Code of Practice for Health Assessment of Rail Safety Workers 3 Table 1. Criteria for Selection of Authorised Health Professionals
Safety Critical Workers (Categories 1 and Around the Track Personnel (Category 3) 2) health assessments health assessments Qualifications and Experience: The health Qualifications and Experience: The health professional must have a qualification in medicine professional should have a qualification in medicine and should have interest or experience in or a nursing qualification with a postgraduate occupational medicine. qualification in occupational health nursing. For a medical professional, interest and experience in occupational medicine is desirable.
Rail Industry Knowledge: The health professional Rail Industry Knowledge: The health professional should demonstrate understanding of the rail should demonstrate understanding of the rail industry environment including work performed industry environment including work performed and risks involved. and risks involved.
Code of Practice: The health professional should Code of Practice: The health professional should demonstrate familiarity with the Code of Practice demonstrate familiarity with the Code of Practice for Health Assessment of Rail Safety Workers for Health Assessment of Rail Safety Workers and a working knowledge of Volume 2 of the and a working knowledge of Volume 2 of the Code, Health Assessment Procedures and Code, Health Assessment Procedures and Medical Criteria, including: Medical Criteria, including: • Appreciation of the role of health assessments • Appreciation of the role of health assessments in ensuring rail safety. in rail safety. • Familiarity with the risk management approach • Familiarity with the risk management approach used to identify the level of health assessment used to identify the level of health assessment required. requirements. • Familiarity with the tasks in rail operations and • Familiarity with the tasks in rail operation and with major tasks of Safety Critical Workers. experience of major tasks of the Around the • Knowledge of rail safety worker risk Track Personnel. categories and the rationale for health • Knowledge of rail safety worker categories of assessments applied. and the rationale for health assessments • Knowledge of and ability to perform the applied. Safety Critical Worker Health Assessment. • Knowledge of and ability to perform the • Understanding of requirements and reporting Track Safety Health Assessment. options for fitness for rail safety duty. • Understanding of requirements and reporting • Knowledge of the assessment’s options for fitness for rail safety duty. administrative requirements, including form • Knowledge of the assessment’s completion and record keeping. administrative requirements, including form • Understanding of ethical and legal completion and record keeping. obligations and the ability to conduct health • Understanding of ethical and legal obligations assessments accordingly, including and the ability to conduct health assessments appropriate communication with the worker accordingly, including appropriate and the employer. communication with the worker and the • Understanding of ethical issues in employer. relationships with the treating doctor/GP. • Understanding of ethical issues in relationships with the treating doctor/GP.
Interfacing Policies and Programs. The health professional should be able to demonstrate awareness of legislation, policies or programs that might interface with or affect the performance of the health assessment for example, drug and alcohol policy, critical incident management programs, anti-discrimination legislation and privacy legislation.
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3.2 Primary Purpose on a clear understanding of the various responsibilities as well as effective Health information can only be disclosed communication between the individuals/ for the primary purpose for which it was groups involved. Such communication, collected, that is for assessing fitness for including management of health records, rail safety duty. Only information justifiably should be consistent with the provisions of necessary to assess fitness for rail safety relevant privacy and health records legislation work should be collected. as discussed in the previous section. The authorised health professional must Following is a summary of the not disclose the worker’s clinical records to responsibilities of the key parties and their the rail organisation. The rail organisation interrelationships. Diagram 2 illustrates needs to know fitness for duty (or any health these relationships and the flow of restrictions), not the underlying medical information that should take place in conditions. conducting rail safety worker health This Volume includes model forms which assessments. assist the authorised health professional to report to the rail organisation in compliance 4.1 Accredited Rail Organisations with Privacy Principles. The rail organisation The accredited rail organisation has a legal cannot request an examination outside the responsibility under the Transport Act 1983 health requirements of the worker’s job and to ensure systems are in place to protect the cannot provide the examining health safety of the network and public safety. This professional with information that is not includes a responsibility to ensure that the relevant to the health assessment for that health and fitness of workers is monitored job. and does not jeopardise rail safety. 3.3 Information disclosure As an employer, the accredited rail organisation has a duty of care under Worker/patient consent must be obtained occupational health and safety legislation to disclose any health information to a third to the safety of its workers. party unless permitted by law as with workers compensation. Where possible, to meet anti-discrimination requirements, the employer should 3.4 Maintenance of Information accommodate the limitations of the worker’s capabilities due to health issues through Information should be kept accurate, up to strategies such as job modifications, date and protected from loss and alternative or supervised duties as unauthorised use. appropriate. Records may be scanned and kept in If employing contractors, the employer is electronic form. The worker’s signature on required to inform them of their obligations the completed Safety Critical Worker to ensure appropriate health assessment Health Questionnaire is legally valid after systems are in place for their workers. scanning. 4.2 Contractors 3.5 Interstate considerations An accredited rail organisation is responsible Where it is necessary for interstate workers, for managing its contractors and ensuring information should only be transferred to that contractors meet their responsibilities other states or territories where privacy for rail safety worker health assessments. laws are similar. 4.3 Rail Safety Workers 4. Responsibilities and Rail safety workers have a duty of care to Relationships themselves and others. Once employed, The successful implementation of health they should know their job, its implications assessments for rail safety workers relies for rail network and public safety and the
Code of Practice for Health Assessment of Rail Safety Workers 5 importance of their health and fitness to rail 4.4 Health Professionals safety. Health professionals appointed and They have a responsibility to notify the authorised by the accredited rail organisation employer of any temporary or ongoing should have demonstrated that they have health condition or change in health status relevant competence and understanding of that is likely to affect their ability to the rail environment to conduct health undertake their work safely. They must assessments for rail safety work. also comply with any review requirements The authorised health professionals should of a health assessment. conduct health assessments in line with the Rail safety workers are also responsible for procedures contained in this Volume 2: advising their employer of impairment due Assessment Procedures and Medical to medication. Criteria. Rail safety workers may request referral to The relationship between the health an authorised health professional if they professional and the worker/patient is are concerned about their ability to perform governed by the ethics of the relevant their work safely due to health reasons. health profession and by privacy laws. If rail safety workers work for more than The relationship differs from the usual one organisation they have a responsibility doctor-patient relationship because of the to ensure each employer is advised about involvement of a third party, the employer. conditions that may affect their safe The health professional should not provide working ability. personal or medical information to the employer, only information regarding work capacity.
Diagram 2. Relationships in the Implementation of Health Assessments for Rail Safety Workers
6 Department of Infrastructure The final decision regarding fitness for duty network and those who do not work on the or any restrictions rests with the employer Victorian network but whose actions affect and may involve consideration of anti- it, for example train controllers. discrimination and retraining issues. The authorised health professional should 5.1 Categorisation of Rail Safety liaise with the worker’s general practitioner Workers According to Risk and treating specialists where appropriate The requirements for health assessments to clarify information relating to the worker’s of rail safety workers are determined by a current health status. Such communication risk management approach. should occur with the consent of the worker. The methodology for this approach is The ongoing treatment and management of summarised in Diagram 3. The steps are medical conditions should be the responsibility explained in detail in the Guideline for of the worker's general practitioner. Health Risk Management and examples Authorised health professionals should are provided. communicate and consult with the general practitioner and other relevant providers to The employer is responsible for analysing ensure the effective management of the the risks associated with the rail safety worker’s health. work performed in their operations and for assigning a risk category to each rail safety The authorised health professional may also worker. liaise with the rail organisation’s Medical Officer, if they have one. The medical The risk management approach aims to officer may access worker’s medical records ensure the level of health assessment but is bound by privacy considerations. conducted is commensurate with the risk associated with the tasks performed by the rail safety worker. As the work environment 5. Workers Who Require a significantly determines the skills required Health Assessment and risk involved, a risk analysis should Workers who carry out rail safety work for form the basis of all rail safety worker health accredited rail organisations require a assessment decisions. health assessment to determine their health The key criterion applied in the risk analysis and fitness for duty. is the extent to which the workers’ health Section 93 of the Transport Act 1983 defines both physical and psychological, may a rail safety worker to include an employee, impact on the safety of the rail network and contractor, subcontractor or volunteer the public. The nature of the task and the performing work on a railway or tramway engineering controls available are both system: considered in the risk assessment. This has led to the establishment of two main • as a driver, second person, trainee risk categories: driver, guard, conductor, supervisor, observer or authorised officer; • Safety Critical Work • as a signal operator, shunter or person • Non-Safety Critical Work who performs other work relating to the These two main categories are further movement of trains or trams; divided into four risk categories overall. • in repairs, maintenance, or upgrade of They help to define broad physical and railway infrastructure, including for rolling psychological health attributes needed for stock or associated works or equipment; particular rail safety tasks. The system allows for the identification of task-specific • in construction or as a look out for health attributes such as levels of colour construction or maintenance; and vision. • any other work that may be included by regulation. These two main categories are further divided resulting in four risk categories overall. This includes interstate-based workers required to work on the Victorian rail
Code of Practice for Health Assessment of Rail Safety Workers 7 Diagram 3. Definition of Risk Categories for Rail Safety Work
Rail Safety Worker
Identify the full range of tasks likely to be performed by the worker and consider the engineering and procedural environment including controls.
For any aspect of the tasks identified, could ill health lead directly to a serious incident affecting the YES public or the rail network? NO
SAFETY CRITICAL NON-SAFETY CRITICAL
For any aspect of the tasks identified, could Is the person Around the Track Personnel? sudden incapacity lead to a serious incident ie Is any aspect of the tasks identified affecting the public or the rail network? performed “on or about the track”?
YES NO
Are all aspects of the tasks identified performed YES within a declared YES NO Controlled Environment?
NO
CATEGORY 1 CATEGORY 2 CATEGORY 3 CATEGORY 4 High Level Safety Safety Critical ATTP in ATTP in Critical Worker Worker Uncontrolled Controlled (HSCW) (SCW) Environment Environment Health requirements: Health requirements: Health requirements: No rail safety ! No risk of sudden ! Physical and ! Hearing and vision specific health attributes incapacity psychological ! Mobility ! Physical and health psychological RISK CATEGORY health
High Level SCW SCW Health Track Safety Health No rail safety health Health Assessment Assessment aims to: Assessment aims to: assessment required. aims to: ! Assess overall ! Assess hearing ! ± OHS ! Identify risk of physical and and vision sudden incapacity psychological ! Assess mobility health ! Assess overall ! ± OHS physical and ! ± OHS psychological health ! ± OHS HEALTH ASSESSMENT
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5.2 Safety Critical Workers Their risk category depends on their likely exposure to moving rolling stock. Safety Critical Workers are defined as those workers whose action or inaction, due to ill There are two Non-Safety Critical Worker health, may lead directly to a serious risk categories. incident affecting the rail network. ATTP operating in an Uncontrolled The health and fitness of these workers, Environment (Category 3) especially their vigilance and attentiveness Where ATTP cannot be protected by a to their job, is crucial and they are therefore Controlled Environment they must have the the main focus of this Code. ability to sense an oncoming train and move Safety Critical Workers’ tasks are those that quickly out of the way. They are therefore might affect the safety of the public and the required to have health assessments network and are distinguished from tasks commensurate with these risks, including that affect only individual safety. They are appropriate hearing, vision and mobility. also distinguished from tasks where skill ATTP operating in a Controlled has the main bearing on rail safety and ill Environment (Category 4) health is a lesser consideration. The risk to ATTP may be reduced by There are two Safety Critical Worker risk creating a Controlled Environment. Workers categories. in a Controlled Environment do not need to rely on their vision, hearing and mobility to High Level Safety Critical Worker protect them from risk and do not require a (Category 1) health assessment. High Level Safety Critical tasks are those Where workers may move between where a serious incident affecting the Controlled and Uncontrolled Environments public or the network could result from the higher level of risk assessment should sudden worker incapacity such as heart be applied. attack or blackouts. Single operator train driving on the commercial network is an example of a High Level Safety Critical 6. Matching the Level of task. Health Assessment to Safety Critical Worker (Category 2) Risk Category Safety Critical tasks that are not High Level After assigning a risk category to the worker, include those where fail-safe mechanisms the employer will match the worker to the ensure sudden incapacity does not affect appropriate level of health assessment safety of the rail network. For example, in before referral to the health professional. many cases the signalling task is Safety The health assessment requirements for Critical but not High Level Safety Critical the four risk categories for rail safety because fail-safe systems ensure the safety workers are summarised below. of the network in case of worker incapacity. 6.1 Safety Critical Health 5.3 Non-Safety Critical Workers Assessments (Categories 1 Non Safety Critical Workers are those whose and 2) health and fitness will not impact directly on Safety Critical Workers should undergo a the safety of the public and the rail network. comprehensive physical and psychological These workers are categorised based on assessment at pre-placement, or change of whether their health and fitness will impact grade and periodically during employment. on their ability to protect their own safety This is to detect conditions that may affect and that of fellow workers. safe working ability (for example heart Around the Track Personnel (ATTP) is the disease, diabetes, epilepsy, sleep disorders, term used to describe workers who perform alcohol and drug dependence, psychiatric Non-Safety Critical tasks on or near the disorders and eye and ear problems). track as defined.
Code of Practice for Health Assessment of Rail Safety Workers 9 The assessment comprises a questionnaire Results are combined with other risk factors and clinical examination. It may also include such as age, cigarette smoking and blood drug screening at pre-placement/change of pressure to calculate a Cardiac Risk Score grade, or for a “show cause” Triggered on which to base predictions. Health Assessment in line with Victorian Other conditions likely to cause sudden legislative requirements. incapacity and hence loss of control of Safety Critical Worker Questionnaire safety critical work also need to be carefully assessed, (for example epilepsy, This self-administered questionnaire collects hypoglycaemia, heart block, Transient a general history and helps screen for Ischaemic Attacks, etc) as do conditions specific conditions that might affect rail which cause inattentiveness such as safety task performance. These include: excessive daytime sleepiness or anxiety • sleep disorders (Epworth Sleepiness states. Scale); • alcohol dependency (AUDIT 6.3 Track Safety Health Questionnaire); and Assessment (Category 3) • psychological problems (K10 The Track Safety Health Assessment for Questionnaire). ATTP (Category 3) comprises eyesight and The questionnaire is not diagnostic and no hearing tests and an assessment to ensure decision should be made regarding fitness safe mobility around the track. for duty until the clinical examination is complete. However upon completion of the 6.4 Task-Specific Requirements assessment it may be necessary to declare The health assessment categories provide a patient Temporarily Unfit for Duty whilst a general framework for defining health further tests are being performed so a assessment needs. However certain tasks diagnosis can be firmly established on have specific requirements, for example for which to base management. colour vision and/or hearing and/or Clinical Examination musculoskeletal attributes. The clinical examination assesses the key The rail organisation will identify such body systems to identify conditions that requirements and communicate these to might affect rail safety task performance the health professional. including cardiovascular, neurological, Screen-Based Equipment (SBE) psychological, musculoskeletal and visual Examinations systems. Referral for further tests or opinion may be required. All persons who work 25% or more of their time on SBE should be routinely tested: 6.2 High Level Safety Critical • pre-commencement on SBE; Health Assessments • every two years over the age of 40 (Category 1): additional years; and requirements for • whenever symptoms indicate a problem In addition to the components of the Safety may exist. Critical Worker Health Assessment, a High Level Safety Critical Worker must have a 6.5 Practical Tests Cardiac Risk Score assessment to identify In some situations a clinical health their risk of cardiovascular disease and assessment may need to be supplemented collapse or incapacity from heart attack. by a practical test to confirm fitness for duty. Tests include: For example, practical tests for colour vision, • fasting plasma glucose; hearing or musculoskeletal capacity may • fasting serum cholesterol (total and be applied to confirm the worker’s alibility HDL); and to conduct the particular tasks required of them. • resting ECG.
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Practical tests may be conducted by persons 7.1 Pre-placement or Change of appropriately trained in the test procedure Grade Health Assessments and with experience of the tasks involved, eg a principal driver. Rail safety workers classified in Categories 1, 2 and 3 require health assessments at Each rail organisation should develop their pre-placement and before changing to a own procedures and criteria for practical higher grade. testing based on their system requirements. Principles of practical testing for hearing, These assess a worker’s suitability for rail vision and musculoskeletal capacity are safety duties and should match the risk outlined in this volume. category of the job they are entering.
6.6 Drug and Alcohol Screening 7.2 Periodic Health Assessments Accredited rail organisations must have Periodic Health Assessments aim to identify procedures to ensure that rail safety workers health conditions that may affect safe are not impaired by alcohol or drugs when performance of rail safety work. They should performing their work. Rail safety worker’s be conducted for Category 1, 2 and 3 rail themselves also have a duty not to perform safety workers according to the defined rail safety work whilst impaired by alcohol frequencies. or drugs. Category 1 and 2 Safety Critical Worker Pre-placement and/or Change of Grade • At time of commencement then Health Assessments for Safety Critical • 5 yearly to age 50 Workers therefore include a drug screen. • 2 yearly to age 60 Periodic Health Assessments for Safety • Yearly thereafter Critical Workers generally do not include a drug screen. However, assessment for Category 3: ATTP in Uncontrolled drug or alcohol dependence is an aspect of Environment the Safety Critical Worker Health • At time of commencement then Assessment. • at age 40 and 5 yearly thereafter This Volume includes guidance and criteria The frequencies are a minimum requirement for authorised health professionals to assess based on evidence of rate of age-associated drug or alcohol dependence as well as degenerative illness, the increased power guidance for managing a situation where of the revised assessment to detect rail acute drug or alcohol impairment is safety workers at risk and comparison with suspected at a Periodic Health Assessment. local and overseas standards.
7. Types of Health Employers may choose to implement more frequent Periodic Health Assessments Assessments Required should the need and rationale be identified. There are three types of health assessments An authorised health professional may also for rail safety workers illustrated in Diagram recommend more frequent assessments 4. These aim to: for the purpose of health surveillance (ie • confirm that a rail safety worker candidate Triggered Health Assessment), depending is medically suited to the tasks to be on the needs of the individual worker. performed; Ongoing treatment of medical conditions • periodically monitor the rail safety worker’s should continue to be the responsibility of health during employment to detect the worker's general practitioner. conditions that might affect rail safety; and The program of comprehensive Periodic Health Assessments should be maintained • enable a timely response to concerns even if more frequent Triggered Health about the worker’s health Assessments are performed for an individual’s particular condition.
Code of Practice for Health Assessment of Rail Safety Workers 11 Diagram 4. Health Assessments Supporting Fitness for Rail Safety Work
7.3 Triggered Health Assessments anxiety states, are not age dependent and onset patterns are not clearly defined. Triggered Health Assessments are Therefore they may not be readily identified conducted in response to incidents or at a Periodic Health Assessment. concerns regarding the worker’s ability to perform their job safely. They are likely to Employers should be alert to indicators of address a particular health issue and ill health such as recurrent absenteeism, include scheduled review assessments for repeated incidents and recent traumatic conditional fitness for duty (Fit for Duty events and discuss these with the rail Subject to Review). safety worker. This may lead to triggered Triggered Health Assessments aim for referral for health or neuropsychology early intervention and appropriate assessment, retraining in competencies or management of health problems likely to to the Employee Assistance Program. affect safety. They overlay Periodic Health To ensure appropriate referrals and Assessments and help to identify and transparency in decision-making, the rail manage illness of unpredictable and rapid organisation should develop and distribute onset. clear referral criteria for Triggered Health Assessments.
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Examples of trigger situations include: Sick leave review systems should support and validate such referrals. Scheduled Review Assessments (Fitness for Duty Subject to Review) Accident/Incident Patterns Health assessments scheduled for Accident/incident patterns may indicate workers assessed Fit for Duty Subject to worker difficulties or health issues. The Review or Temporarily Unfit for Duty rail organisation’s incident investigation Subject to Review are the most common and management procedures should triggered referrals. They are more consider potential health (including frequent than standard periodic reviews to psychological) issues and refer for health allow closer monitoring of a health condition. assessment as required. Review intervals are recommended by the At Worker’s Request health professional. Workers should be advised to report to the Sick Leave and Patterns of Absenteeism employer any illness or health problem Workers who have been absent from work likely to affect their ability to work safely, due to an injury or illness and who have a including impairment from medication as condition that may adversely affect their required by statutory drug control ability to perform rail safety duties, should provisions. be assessed for fitness for duty before Table 2 summarises the health returning to work, taking account of their assessment requirements and types of rehabilitation plan. health assessments for the various Recurrent absenteeism may also flag the categories of rail safety worker. need for referral for health assessment.
Table 2. Summary of Health Assessment Requirements for Rail Safety Workers
CATEGORY 1 - High Level Safety Critical Worker Workers performing tasks critical to rail network safety and whose action, inaction or collapse, due to ill-health, may lead directly to a serious incident affecting the network. Type of Health Assessment Required Frequency
Preplacement / Upgrade Health Assessments On commencement and when moving to a higher grade. Safety Critical Worker Health Assessment including: • Safety Critical Worker Questionnaire & history • Comprehensive physical and psychological assessment • Vision and hearing • Screen-based equipment (SBE) examination if required • Drug Screen if required plus • Cardiac Risk Score Additional health assessments may be implemented to meet OHS requirements Periodic Health Assessments Safety Critical Worker Health Assessment including: • 5 yearly to age 50 • Safety Critical Worker Questionnaire & history • 2 yearly to age 60 • Comprehensive physical and psychological assessment • Yearly thereafter
• Vision and hearing Note: Depending on the needs of the worker, • Hearing assessment authorised health professionals may also recommend more frequent assessments for • Screen-based equipment (SBE) examination if required plus health surveillance. Ongoing treatment and • Cardiac Risk Score management of medical conditions should continue to be the responsibility of the worker's Additional health assessments may be implemented to meet OHS General Practitioner. requirements.
Triggered Health Assessments As determined by circumstances Nature of health assessment will depend on the triggering circumstances.
Code of Practice for Health Assessment of Rail Safety Workers 13
CATEGORY 2 - Safety Critical Worker Workers performing tasks critical to rail network safety whose action or inaction, due to ill health, may lead directly to a serious incident affecting the network. Type of Health Assessment Required Frequency
Preplacement / Upgrade Health Assessments On commencement and when moving Safety Critical Worker Health Assessment including: to a higher grade. • Safety Critical Worker Questionnaire & history • Comprehensive physical and psychological assessment • Vision and hearing • Screen-based equipment (SBE) examination if required • Drug Screen if required Additional health assessments may be implemented to meet OH&S requirements. Periodic Health Assessments • 5 yearly to age 50 Safety Critical Worker Health Assessment including: • 2 yearly to age 60 • Safety Critical Worker Questionnaire & history • yearly thereafter • Comprehensive physical and psychological assessment
• Vision and hearing Note: Depending on the needs of the worker, authorised health professionals may also • Screen-based equipment (SBE) examination if required recommend more frequent assessments for Additional health assessments may be implemented to meet OH&S health surveillance. Ongoing treatment and requirements. management of medical conditions should continue to be the responsibility of the worker's General Practitioner. Triggered Health Assessments As determined by circumstances Nature of health assessment will depend on the triggering circumstances.
CATEGORY 3 - Around the Track Personnel operating in an Uncontrolled Environment Those workers who are required to operate within the recognised safety envelope but without engineering or administrative controls to protect them from moving rolling stock, and whose action or inaction due to ill-health may endanger their safety or those of work colleagues.
Type of Health Assessment Required Frequency
Preplacement /Upgrade Health Assessments On commencement and when moving Track Safety Health Assessment including: to a higher grade. • Vision and hearing • Mobility • Drug Screen as determined by task risk analysis. Additional health assessments may be implemented to meet OHS requirements.
Periodic Health Assessments • At age 40 and 5 yearly thereafter Track Safety Assessment including: • Vision and hearing Note: Depending on the needs of the worker, authorised health professionals may also • Mobility recommend more frequent assessments for Additional health assessments may be implemented to meet OHS health surveillance. Ongoing treatment and management of medical conditions should requirements. continue to be the responsibility of the worker's General Practitioner. Triggered Health Assessments As determined by circumstances Nature of health assessment will depend on the triggering circumstances.
CATEGORY 4 Other than those in Categories 1-3 Type of Health Assessment Required Frequency
No prescribed health assessment for rail safety purposes. N/A Health assessments may be implemented to meet OHS requirements.
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8. Procedures for Conducting (if relevant) and/or indication of a positive Health Assessments alcohol or drug impairment assessment. The Safety Critical Worker should also be The administrative, clinical and reporting asked to bring all medications or a list of procedures which should be followed by their medications to the appointment. the authorised health professional in conducting health assessments for rail By agreement between the examining safety workers are described below. health professional and the employer, the worker may have been requested to attend 8.1. Clinical Appointment and for an audiogram prior to examination. Documentation 8.2 Facilities and Equipment An appointment for an assessment will be made either by the employer or the worker. The examination room should be well lit, quiet and offer privacy with a nearby toilet. Prior to the appointment the employer will Equipment should include: forward to the health professional the relevant forms and documentation. The • Snellan chart, Ishihara plates (45cm health professional should not conduct the and 70cm acuity tests, or referral to assessment without the appropriate forms. optometrist for SBE testing). • Sphygmomanometer. Model Forms are included in Part 4 of this Volume and include: • Urine test container and dipsticks. • Health Assessment Request and • Lap top/PC for recording data and Report Form (Blue Form) which will calculating risk score (optional). indicate the nature of the worker’s job and the level (eg Category 1) and type 8.3 Orienting the Worker/Patient (eg Pre-placement) of health assessment To orient and inform the worker about the required; health assessment procedure: • Safety Critical Worker Questionnaire • Exchange normal greetings and (Pink Form) which the worker should names. have completed and brought to the appointment; and • Check the ID photo of the person. • Health Assessment Record (Green • Formally explain to the worker the Form) which guides the clinical purpose of the health assessment, and examination and provides a useful that the results will be discussed with guide and convenient standardised them. template for recording a general • Formally explain Privacy Principles: all assessment of fitness for rail safety duty. clinical and health information will remain confidential and will not be forwarded to High Level Safety Critical Workers will the employer without the worker’s require an ECG and blood test prior to the consent. The report provided to appointment. These should be completed management will be in functional terms in advance and the results forwarded to in relation to their fitness to perform rail you directly. safety duties, as indicated on the Blue Safety Critical Workers should also bring Form. supporting documentation to a Periodic Assessment. The employer will indicate on 8.4 Safety Critical Worker the Blue Form what documentation from Questionnaire the list has been included as relevant to the A Safety Critical Worker (Category 1 or 2) case. attending for a Periodic Health Assessment This should include a copy of the report should bring a completed Safety Critical from the previous health assessment and Worker Questionnaire. The assessment may include summary reports of sick leave, should not proceed unless this has been Workcover claims, notifiable incident history completed.
Code of Practice for Health Assessment of Rail Safety Workers 15 Review the worker’s responses to the and to agree an approach to management questionnaire. Elicit further information as such as baseline biochemistry, or referral required. to GP or to Employee Assistance Program. Calculate scores for various sections of the If during a Periodic Health Assessment, the questionnaire and record the results on the examining health professional identifies Health Assessment Record (Green Form). apparent acute alcohol impairment, this These sections include: should be managed according to the • Epworth Sleepiness Scale (Question 4) specific chapter in Part 2A addressing Alcohol Dependence and Impairment. • alcohol AUDIT questionnaire (Question 5) • K10 questionnaire (Question 6). In cases where the patient shows dependency or impairment they will need Clarify and discuss aspects of the to be immediately classed Temporarily questionnaire as required to establish Unfit for Duty pending further assessment. history. Cardiovascular Request the person to sign the questionnaire as a truthful statement, then countersign The Cardiac Risk Score and date. The worker may also indicate Should include: their consent to their treating doctor to be • Blood pressure - this may be taken contacted. sitting or supine 8.5 Clinical Assessments relevant • Pulse rate to the Worker’s Risk Category • Heart sounds When examining a worker to assess their • Peripheral pulses fitness for duty, the functionality of various • Cardiac Risk Score (High Level Safety body systems should be addressed as Critical Workers, Category 1 only). outlined in Part 2 of this Volume. Note worker’s age, whether they are a smoker, blood pressure, ECG results, Additional tests or referral to a specialist fasting cholesterol (total and HDL) and may be required if and when clinical fasting plasma glucose. For scoring, examination raises the possibility of see Part 2A, Cardiovascular Diseases. potentially significant problems. Chest/lungs and Abdomen 8.6 Safety Critical Workers Should be examined, but a genital (Categories 1 and 2) examination is not required. Health Assessments for Safety Critical Drug Dependence or Impairment Worker (Categories 1 and 2) require assessment of all the following areas, Drug screening may be required for Pre- discussed alphabetically as presented in placement/Change of Grade Health Part 2: Assessments or for a specifically referred Triggered Health Assessment. Screening Alcohol Dependence or Impairment should be conducted in line with The main purpose of the health assessment Australian/New Zealand Standard with respect to alcohol is to examine for 4308:2001: Procedures for the Collection, harmful drinking patterns or alcohol Detection and Quantification of Drugs of dependence. Abuse in Urine. Consider the result of the Audit Questionnaire If during a Periodic Health Assessment, the (Question 5 of the Safety Critical Worker examining health professional identifies Health Questionnaire) together with relevant impairment which has no apparent medical history, and/or clinical signs. If the score is basis, this should be managed according to raised (≥ 8) or other clinical findings the specific chapters in Part 2A addressing warrant it discuss the findings with the Drugs (Illicit and Prescribed or OTC). worker to determine possible explanations
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In cases where the worker shows Sleep dependency or impairment they will need to Consider the result of the Epworth be immediately classed Temporarily Unfit Sleepiness Scale score (Question 4 of the for Duty pending further assessment. Safety Critical Worker Health Questionnaire) Hearing together with relevant history, clinical signs etc. If facilities are available conduct audiometry according to procedures outlined in Part If the score is raised (≥16) or other clinical 2A, Hearing. Alternatively an audiologist findings warrant it discuss the findings with report will be provided with the health the patient to determine possible assessment request. explanations and to agree an approach to Neurological/Locomotor management eg referral to GP, or referral to sleep clinic for polysomnography, or An assessment of neurological and letter to management about roster (Fit for locomotor function should be aligned with Duty Subject to Job Modification), etc. In the specific requirements of the worker’s some cases the worker will need to be task but will generally involve assessment immediately classed Temporarily Unfit for of the following: Duty pending further assessment (refer • Ability to flex, extend and rotate head; Part 2A, Sleep Disorders). • Ability to raise arms above head by Urinalysis swinging them outwards; Urine should be tested for protein and • Alibility to flex and extend arms, and sugar. grasp hands; Vision • Ability to flex trunk to reach about the knees. Visual acuity is tested with a Snellan chart The assessment should also involve that includes at least five letters on the 6/12 observation of the worker’ gait and line, at a distance of 6m (or scaled to 3m). performance of a Romberg Test. Explain what is required to the worker and ask them to read lines near the top to Psychological Health familiarise them with the chart. Consider the result of the K10 questionnaire Visual acuity should be measured one eye (Question 6 of the Safety Critical Workers at a time (monocularly) without correction Health Questionnaire) together with other in the first place. More than two errors in relevant history, clinical signs and reading the letters of any line is regarded accidents/incident patterns reported by the as a failure to read the line. rail organisation. Fields. Sit about 1m from the worker. Ask If the score is raised (≥19) or other clinical them to look at your nose. Extend your observations warrant it, discuss the findings arms to be halfway between you and just with the worker to determine possible within your own field of vision. Ask the explanations such as work stress, domestic worker to indicate to you when they notice crises or endogenous causes, and agree your finger movement. Perform this test at an approach to management of the 180o right and left, and various other condition such as referral to GP/psychiatrist points. Any defect in visual field should or to an Employee Assistance Program. lead to referral for detailed assessment. In some cases the worker will need to be Colour Vision is screened for using Ishihara immediately classed Temporarily Unfit for plates under good illumination. Show the Duty pending further assessment (refer worker the trial plate and explain the test. Part 2A, Psychiatric Disorders). Then proceed to show the colour plates with numbers, noting any errors. The colour vision standards (“colour vision normal” and “colour vision defective safe”) vary between jobs and the section on
Code of Practice for Health Assessment of Rail Safety Workers 17 Vision should be referred to for specific requirements for managing the worker. advice. The Case Studies in Part 3 also illustrate how these levels of fitness for duty are Screen Based Equipment eye examination. applied in practice. Suitability to work with screen-based equipment is screened for using the proforma provided including eye chart at 45 and 70cm. 9.1 Functional Classifications for Reporting 8.7 Additional Tests and Rail The functional classification of a worker’s Specific Resources fitness for duty are provided in the Code of Practice and in the Blue Form. Note that: To further assist in assessment there are some additional tests and rail specific • determinations may be combined; resources to be aware of: • a particular worker may move from one Neuropsychological Tests classification to another as you progress through the medical assessment and Neuropsychological tests regarding aptitudes investigation process. for drivers of trains have been specifically developed for use in recruitment and other Fit for Duty situations. They may be used for This indicates that the person has met all assessment of drivers who have had injury the criteria in the standard and is to be or illness affecting mental processes to help reviewed in line with the normal Periodic gauge their recovery and suitability for work. Health Assessment schedule. The tests should be applied by a psychologist experienced in their use. Fit for Duty Subject to Review Principal Drivers This indicates that the person has not fully met all the criteria in the standard, however A Principal Driver (or equivalent) is a senior the condition in question is sufficiently driver with wide experience who is often under control that normal duties may be involved in training other drivers. A worker permitted. Continuation of normal duties with borderline impairment may be referred would be conditional on the person being to a Principal Driver for a practical test. This reviewed more frequently than the Periodic is particularly relevant to musculoskeletal Health Assessment schedule requires. and neurological impairments. Such an The review period is specified by the assessment should be arranged through authorised health professional. the worker’s management and could be in conjunction with a physiotherapist or Fit for Duty Subject to Job Modification occupational therapist if the opinion of such This indicates that the person does not fully a professional is also needed. meet all the criteria of the standard, but could undertake current rail safety duties if 8.8 Track Safety Assessments for suitable modifications were made to the Category 3 job. These modifications may include: The Track Safety Health Assessment • physical changes to equipment; (Category 3) requires assessment of vision, • changes to rosters eg to help manage hearing and mobility only. sleep disorders; or • requirements for the worker to operate 9. Fitness for Duty under supervision. Classifications Job modifications may not be practicable in To assess the fitness for rail safety duty, the various areas of rail safety work. For results of the health assessment should be example, drivers are expected to drive any considered in relation to the specific criteria locomotive or tram for which they are outlined in Part 2 of this Volume. trained and hence proposed job modifications may require discussion with The various levels of fitness for duty are the worker and supervisor. described below, including reference to the
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Temporarily Unfit for Duty Subject to Each situation will need to be assessed Review individually, with due consideration being given to the probability of a serious disease This indicates the worker has not met all which will affect rails safety work. criteria in the standard and cannot perform current rail safety duties at present. However, Generally, a Safety Critical Worker who the condition is anticipated to improve with presents with symptoms of a potentially treatment and the worker will be reviewed serious nature, for example chest pains, to determine fitness status. This differs blackouts, delusional states, dizzy spells from ordinary short-term illness causing and the like, should be assessed Temporarily absenteeism. Unfit for Duty until their condition can be adequately assessed. However, they may Temporarily Unfit for Duty may also be be assessed as fit for alternative duties. applied in situations where a clear diagnosis has not been made in the case of an Complex Conditions and conditions not undifferentiated illness, for example where covered in the Code a worker is being investigated for blackouts. Where a worker has a systemic disorder of The examining health professional should a number of medical conditions, there may advise about the period for review. The be additive or cumulative detrimental effects worker may be assessed fit for alternative on judgement and overall function. For duties. example, there may be a combination of Permanently Unfit for Duty impaired vision, hearing and locomotor dysfunction or combinations of physical and This indicates the worker has not met all mental illness and associated medication. If criteria in the standard, their condition is these or other clinical condition are not permanent and they will not be able to adequately covered in Part 2, the health perform current rail safety duties in the professional should consider: future. Normal company policies such as for redeployment may be considered. • The nature of the worker’s tasks and the worker’s capacity to perform the 9.2 Additional considerations duties safely. The key issue to consider is: could the condition affect vigilance Temporary Illnesses or lead to sudden collapse and affect The Code of Practice does not presume to safety of the rail network? deal with the myriad of conditions that may • The modification of tasks or the affect health on a short-term basis and for environment to accommodate a person’s which a rail safety worker may be referred condition without compromising their for assessment regarding fitness to resume efficiency or the health and safety of duty. Such conditions may include post- others, or incurring unreasonable major surgery, severe migraine, fractures expense. to limbs or stress. Clinical judgment is usually required on a 9.3 Specialist Referral case-by-case basis although the text in The worker’s condition may warrant referral each chapter gives some advice on the to a specialist. In such cases the authorised clinical issues to be considered. health professional should explain fully the Undifferentiated Illness nature of the rail safety tasks involved and the concerns regarding health status. The A rail safety worker may be referred with specialist report should be sent to the symptoms which could have implications authorised health professional, not to the for their job but the diagnosis is not clear. employer. Referral and investigation of the symptoms will mean that there is a period of uncertainty 9.4 Informing and Counselling the before a definitive diagnosis is made and Worker before the worker and employer can be confidently advised. The health professional should advise the worker of the results of the assessment and
Code of Practice for Health Assessment of Rail Safety Workers 19 where relevant, about the ways in which • any additional clinical notes. their condition may impair their ability to In addition and in accordance with legislation: conduct rail safety work. As part of this process, the worker becomes better • the worker’s medical records should be informed about the nature of his or her made available to them on request; condition, the extent to which he or she can • the worker’s medical records are subject maintain control over it, the importance of to confidentiality; and regular medical review and the need for • records may be scanned and kept in medication where appropriate. electronic form. The employee’s Should the worker be found unfit for duty, signature on the completed Safety the health professional should take a Critical Worker Health Questionnaire is conciliatory and supportive role while legally valid after scanning. explaining fully the risks posed by the worker’s condition with respect to rail safety 11. Communicating with the work. Worker’s General 9.5 Reporting to the Employer Practitioner and other Health Professionals Should the worker be assessed as Unfit for Duty either temporarily or permanently, the The authorised health professional should health professional should notify the ensure an ethical relationship with the employer immediately by phone to discuss worker’s general practitioner and other the implications of the assessment and to treating professionals and ensure continuity allow the employer to make appropriate of care is maintained. arrangements. The health professional Reference to the general practitioner should should not discuss specific clinical be made for ongoing treatment requirements, information, only recommendations in terms for management of lifestyle issues and to of fitness for duty including any necessary discuss issues such as medication causing job modifications. impairment. In all cases the health professional should The authorised health professional should complete the report section of the Blue Form. obtain the worker’s consent if needing to This report should not include any clinical contact the worker’s general practitioner or information. Only the functional assessment treating specialist to clarify information of fitness for duty or otherwise, and any relating to the worker’s health condition. recommendations regarding specialist review or job modifications and the like Diagram 5 provides a summary of the should be reported to the employer. process involved in conducting a health assessment for fitness for rail safety duties The Questionnaire and Health Assessment and illustrates the roles and responsibilities Record should not be returned to the of the various parties. employer.
10. Record Keeping Appropriate records should be maintained by the authorised health professional including: • completed Safety Critical Worker Health Questionnaire; • completed Health Assessment Record; • copy of the report form sent to the employer; • copies of relevant support information; and
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Diagram 5. Conducting a Health Assessment for Fitness for Rail Safety Duties
EMPLOYER WORKER • Requests report on worker’s fitness to undertake rail safety duties. • Presents for pathology/ECG tests as required. • Provides worker with Health Assessment request & Report Form and identifies the type of health • Brings all current medication. assessment to be undertaken (High Level SCW, SWC or ATTP); and the reason for the assessment • Brings visual ID. (Preplacement/Change of Grade, Periodic, Triggered). • Completes Questionnaire as required (SCW). • Provides Worker Questionnaire Form and Clinical Examination Proforma. • Provides additional information as required including critical incident & Workcover history.
HEALTH PROFESSIONAL • Confirms identification • Reviews questionnaire and other information. • Undertakes health assessment in accordance with the Guidelines for Examining Health Professionals.
Worker Worker Worker Worker Worker assessed as assessed as assessed as assessed as assessed as
FIT FOR DUTY FIT FOR DUTY SUBJECT TO FIT FOR DUTY SUBJECT TO TEMPORARILY NOT FIT FOR PERMANENTLY NOT FIT Meets all relevant medical REVIEW JOB MODIFICATION DUTY FOR DUTY criteria. Does not meet all medical criteria, but Does not meet all medical criteria, but Does not meet all medical criteria Does not meet the medical could work if condition is sufficiently could work if suitable modifications and cannot work at present, but will criteria and cannot perform the under control and person reviewed. were made to the job. be reviewed to determine status. job in the future.
Practitioner completes Health Assessment Report in accordance with findings indicating: • whether fit or otherwise (as above) • recommendations regarding frequency of ongoing review as appropriate. • recommendations regarding specialist review/referral as appropriate. • recommendations regarding practical assessment and job modification as appropriate.
Practitioner also: • Advises and counsels employee accordingly. • Communicates as appropriate with the employee’s GP. • Forwards report to employer by phone if situation warrants immediate communication. • Retains copy of report for file together with original of Employee Questionnaire and Clinical Examination Record.
EMPLOYER WORKER • Makes a decision regarding the employee’s fitness for rail safety duties. • Attends specialist consultations as required. • Advises and implements appropriate practical assessment. • Attends follow-up review appointments as required. • Advises and implements appropriate job modifications. • Advises and implements appropriate medical reviews. • Advises and implements re-deployment as required. Code of Practice for Health Assessment of Rail Safety Workers 21 • Maintains appropriate records and flags dates for review as appropriate.
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PART 2: MEDICAL CRITERIA
Recent advances in the diagnosis and Comparison with Road Standards treatment of various illnesses, combined In September 2003, the National Road with engineering developments and the introduction of anti-discrimination and Transport Commission (NRTC) and privacy legislation, have lead to substantial Austroads released revised medical standards for licensing and managing revision of the medical standards for rail commercial vehicle drivers, Assessing safety workers. Fitness to Drive 2003. These new standards This section outlines the new medical been used as a basis for the rail medical criteria for assessing fitness for rail safety standards, however there are some duty and is arranged in chapters differences between the rail and road alphabetically according to body system or transport environments which are reflected medical condition. Each chapter provides in the new rail standards. general information about the condition and its effects on safety, and then provides Red colour vision, for example, is more advice about the medical assessment of important in the rail industry, as red light the condition. The table in each chapter signals may be single lenses that do not sets out the criteria to be met for fitness for provide positional cues and do not have a rail safety duty. background to highlight the signal. The new Austroads/NRTC standards do The main focus of this section is on serious conditions that would impact on the ability not include a specific assessment tool for to perform rail safety work. The criteria psychiatric health. The K10 questionnaire has been included in the rail standard. emphasise function in relation to the job rather than being based on diagnosis or The sections on Alcohol Dependence and impairment. Specialist advice may be Impairment and Illicit and Prescription Drugs useful regarding assessment of Safety reflect the statutory drug controls that apply Critical Workers. to the rail industry. The risk of a worker having a heart attack is a Levels of Evidence major consideration for the health For each of the chapters the levels of assessment of Safety Critical Workers, evidence for fitness for duty criteria are such as train drivers. Therefore, the noted according to the NHMRC requirements Cardiac Risk Score has been incorporated. (NHRMC. How to Use the Evidence: This is based on data from the American Assessment and Application of Scientific Heart Association and developed by Civil Evidence. 2000.
______1 A risk calculator based on Australian data is being developed at Dept of Epidemiology and Preventive Medicine, Monash University and should be available late 2003. Its use will then be considered
Code of Practice for Health Assessment of Rail Safety Workers 23 PART 2A: MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS
1. ALCOHOL DEPENDENCE AND IMPAIRMENT See also Part 5, Drug and Alcohol Controls, for summary of relevant legislation
1.1 RELEVANCE TO SAFETY CRITICAL Alcohol and Epilepsy WORK Many patients with epilepsy are quite likely to Alcohol Impairment and Legislative have a seizure if they miss their prescribed Requirements medication even for a day or two, particularly when this omission is combined with Alcohol consumption is well known for its inadequate rest, emotional turmoil, irregular acute effects on vigilance and reaction times, meals and alcohol. Patients under treatment and hence increased risk of an error and for any kind of epilepsy are unfit for safety accident occurring. This has lead to critical work if they are frequently intoxicated. legislation and policies aimed at zero blood alcohol when performing rail safety work. Alcohol and Diabetes All states and territories therefore require Patients with diabetes and on insulin have a accredited rail organistions to ensure that rail special problem when they are frequently safety workers are not affected by alcohol intoxicated. Not only may they forget to inject when performing rail safety duties. In Victoria their insulin at the proper time and in the the Transport Act 1983 contains stringent proper quantity, but also their food intake can provisions for alcohol control and all rail get out of balance with the insulin dosage. companies’ alcohol control policies in Victoria This may result in a hypoglycaemic reaction or require a zero blood-alcohol concentration the slow onset of diabetic coma. Such while undertaking rail safety work. A rail persons should not perform safety critical company can require a rail safety worker to work until they no longer drink to excess. submit to an alcohol breath test or blood test if Alcohol and Medication alcohol impairment is suspected while undertaking rail safety work or within three Some medications are incompatible with hours of undertaking rail safety work. ingestion of alcohol (for example some sedatives). Where alcohol is thought to be a This Code of Practice supports alcohol problem, medical practitioners should advise policies through the provision of advice to the patient accordingly and consider authorised health professionals regarding the alternative medication where available. If the management of suspected impairment at the medication is likely to cause any level of time of health assessment. However specific impairment, the practitioner must take procedures for drug and alcohol screening are appropriate steps to restrict involvement in beyond the scope of this standard. safety critical work while on medication, for Harmful Drinking and Alcohol Dependence example, reporting worker as Temporarily Unfit for Duty while on the medication. In addition to the acute effects of alcohol, prolonged high intake may affect the liver or brain and lead to loss of vigilance. The Safety 1.3 ALCOHOL AND ILLICIT DRUGS Critical Worker Health Assessment uses the The use of alcohol in association with a AUDIT questionnaire to assess drinking number of ‘recreational’ drugs such as behaviour and to indicate the need for further marijuana exacerbates their effect and investigation. significantly increases the risk of an error. Therefore where alcohol is thought to be a 1.2 EFFECT OF HABITUAL INTOXICATION problem, consideration should also be given ON OTHER DISEASES to illicit drug use and appropriate steps taken. Alcohol dependent drivers and workers are a particular concern and are disproportionately 1.4 MEDICAL CRITERIA FOR SAFETY represented in (road vehicle) crashes. CRITICAL WORKERS Prolonged alcohol abuse leads to effects on Medical criteria for fitness for duty are outlined end organs such as the brain or peripheral in the table overleaf. nerves or liver, which may lead to further impairment of safety. Persons who are The AUDIT questionnaire should be applied frequently intoxicated and who also suffer as shown in Section 5 of the Safety Critical from certain other medical conditions are often Worker Questionnaire (Part D) and scored as unable to give their other medical problems follows: the careful attention required.
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• Questions 5.1 – 5.8, scores are 0,1,2,3,4, • Withdrawal symptoms on stopping drinking. from left to right. • Relief or avoidance of withdrawal symptoms • Questions 5.9 and 5.10, scores 0,2,4, from by further drinking. left to right. • Subjective awareness of compulsion to • Thus total maximum score is 40. drink (impaired control, urges or cravings). A score of eight or more indicates a strong • Reinstatement of drinking after abstinence. likelihood of hazardous or harmful alcohol The presence of three or more of the above consumption. If the score is raised or other fits the International Classification of Diseases clinical findings warrant it, discuss the findings (ICD) criteria for dependence. with the patient to determine possible explanations and to agree an approach to Binge Drinking: Binge drinking has been management eg, biochemical tests as a defined as the intermittent consumption of baseline, referral to GP or to Employee alcohol to intoxication in short periods of time Assistance Program, etc. In some cases the (six standard drinks for a male and four for a patient will need to be immediately classed female). During binges persons may exhibit Temporarily Unfit for Duty pending further behaviour similar to that of problem drinkers assessment or Fit for Duty Subject to Review. and may be considered unfit for rail safety Referral to a specialist in alcohol may be work. considered. Workers with alcohol problems Tests of blood alcohol are not routinely who are not truthful may score lower on their required at Periodic Health Assessment, but questionnaire than should be the case. biochemical tests for alcohol abuse may be Alcohol Dependence: Alcohol dependence is conducted if clinically indicated or if the worker a syndrome the key elements of which are: is referred for a Triggered Health Assessment. They should be classified Fit for Duty Subject • Narrowing of the drinking repertoire (every to Review or Temporarily Unfit for Duty as days drinking is similar to the day before). appropriate to the clinical appraisal. • Salience of drinking (priority given to In the event of a person presenting for a maintaining alcohol intake and neglect of Periodic Health Assessment with evidence of previously important work and social impairment, an assessment of the impairment activities). should be done and then the person managed • Increased tolerance to alcohol. as shown in Diagram 6.
Diagram 6. Periodic Health Assessment - Management of possible impairment due to alcohol or drugs (illicit and prescription/OTC)
Is there evidence of impairment? Preliminary Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, attitude, comprehension). YES NO
Discuss with worker No further action Is there a medical basis for impairment, ie a medical condition causing impairment or prescription medication or (continue with health OTC drug taken for a defined purpose. assessment) YES NO
Medical basis If suspect alcohol or illicit drug use • Classify Temporarily Unfit for Duty. • Classify Temporarily Unfit for Duty and advise • If appropriate, discuss medication with on report impairment without clear medical GP/treating doctor in order to resolve impact basis. on employment. • Contact employer regarding impairment without • If appropriate, refer to relevant chapter for clear medical basis and await further medical conditions. instructions from employer. • Identify review period.
Code of Practice for Health Assessment of Rail Safety Workers 25
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – ALCOHOL
CONDITION CRITERIA Alcohol The criteria for Fit for Duty are not met: Impairment • If the worker is impaired by alcohol Refer to Diagram 6 for management.
AUDIT The criteria for Fit for Duty are not met: Questionnaire • If the person has an AUDIT score of 8 or greater The person in most cases will be classified Temporarily Unfit for Duty pending review while the causes are being assessed and managed.
Alcohol The criteria for Fit For Duty are not met: Dependency • If there is alcohol dependency; or • If the worker has a strong history of alcohol abuse and clinical evidence of abuse is limited to biochemical findings without clinical signs. Fitness for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work: • If the worker has stopped drinking for a substantial period; and • Demonstrates good evidence of insight into the problem; and • Is compliant with treatments; and • Shows no evidence of end organ damage relevant to safety critical work as specified elsewhere in this Code of Practice.
Temporary Illnesses. The Code of Practice does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which the Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms that could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further reading Arnedt, J.T., et al, Simulated driving performance following Liguori, A.D., et al, Alcohol effects on mood, equilibrium, and prolonged wakefulness and alcohol consumption: separate simulated driving, Alcoholism, Clinical and Experimental and combined contributions to impairment, Journal of Sleep Research, 23(5), 815-821, 1999. Research, 9(3), 233-241, 2000.
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2. ANAESTHESIA
2.1 RELEVANCE TO SAFETY CRITICAL In cases of post-operative recovery following WORK surgery or procedures under general or local anaesthesia, it is the responsibility of the Anaesthesia may affect the ability to perform surgeon and anaesthetist to advise patients Safety Critical Work. Post anaesthesia, both about the potential effects of the anaesthesia physical and mental capacity may be impaired and the need to allow for an appropriate for some time thus affecting a worker’s ability period of physical and mental recovery before to drive and work safely. This is applicable to resuming Safety Critical Work. both general and local anaesthesia. The effects of general anaesthesia will depend on Following minor procedures under local factors such as the duration of anaesthesia, anaesthesia without sedation (for example, the drugs administered, and the surgery dental block), return to work may be performed. The degree of effect of local acceptable immediately following the anaesthesia on the ability to perform Safety procedure. Critical Work is dependent on dosage and Following brief surgery or procedures with region of administration. A further factor to short acting anaesthetic drugs, the patient consider is the effects of analgesics and may be Fit for Duty after a normal night's sedatives (refer Drugs – Prescription and sleep. After longer surgery or procedures OTC). requiring anaesthesia, it may not be safe to 2.2 MEDICAL CRITERIA FOR SAFETY perform Safety Critical Work for 24 hours or CRITICAL WORKERS more. Decisions should be made on a case- by-case basis. There are no specific criteria regarding fitness for duty following-anaesthesia.
Reference: Lichtor, J., Alessl, R., Lane, B. Sleep tendency as a measure of recovery after drugs used for ambulatory surgery. Anesthesiology 2002;96:878-883
Code of Practice for Health Assessment of Rail Safety Workers 27 3. CANCER
3.1 RELEVANCE TO SAFETY CRITICAL 3.2 MEDICAL CRITERIA FOR SAFETY WORK CRITICAL WORKERS Cancer may affect the ability to perform Safety Medical criteria for fitness for duty are outlined Critical Work. The site and degree of in the following table. advancement of the cancer is a prime consideration as to whether a worker remains Cases should be assessed on an individual fit for Safety Critical Work because the cancer basis regarding the site of the cancer, the may affect various body functions. This is response to chemotherapy and radiotherapy particularly important for cerebral tumours. and any side effects. This will also involve Refer elsewhere in this Code for advice assessing the patient’s functional capacity and regarding other specific organ involvement, for what medication the patient is taking.. example, liver metastases. If the tumour involves the brain the patient Treatment with opioids, chemotherapy or should not undertake Safety Critical Work, radiotherapy may present side effects which subject to a health assessment. interfere with an individual’s functional Neuropsychological assessment may be capacity and thus may be incompatible with helpful in this regard. An assessment by a the performance of Safety Critical Work. Principal Driver may also be useful. Palliative Care: Patients with cancer are often prescribed opioids, particularly for palliative care. Safety Critical Workers will require careful individual assessment. (Refer also Drugs – Prescription and OTC).
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – CANCER
CONDITION CRITERIA Cancer The effects at the primary site or of metastases are mainly covered by criteria given elsewhere. Intracranial The criteria for Fit for Duty are not met: tumours • If the person has evidence of primary or secondary cancer within the brain. Fit for Duty Subject to Periodic Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work: • Three months after successful treatment of tumour; and • If the person is likely to remain stable and physical and mental abilities are judged by treating specialist to be adequate for safe working. Neuropsychologist and Principal Driver assessment may be helpful.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which the Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms that could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
28 Department of Infrastructure
4. CARDIOVASCULAR DISEASES
4.1 RELEVANCE TO SAFETY CRITICAL 1. Data WORK Obtain the information for the Cardiac Risk Cardiovascular disease may affect the ability Score calculator as follows: to perform Safety Critical Work due to sudden • Age incapacity such as from a heart attack or an • Cigarette smoking arrhythmia. This is particularly relevant to Category 1, High Level Safety Critical • Blood pressure as measured supine; Workers • ECG - report specifically requiring Symptomatic heart disease as well as pre- information re presence of left ventricular symptomatic disease needs to be detected. hypertrophy; This is made possible through the use of • Fasting blood for Total and HDL screening tests beginning with the Cardiac cholesterol; Risk Score (see below). • Fasting plasma glucose test (level over A Category 1 High Level Safety Critical 7mmol/L is diabetic). Worker such as a train driver, who is 2. Calculation asymptomatic but found to have an increased likelihood of a heart attack on a cardiac risk Calculate the score using Table 4: Coronary score, should be assessed more fully than an Heart Disease Risk Factor Prediction Chart. ordinary patient because of the risks they 3. Stratification and Risk Management pose to rail safety. The risk score limit is set at ≥22 (risk >2%pa).
In the event of a risk score exceeding 22 and 4.2 MEDICAL CRITERIA FOR SAFETY less than 32 where the Safety Critical Worker CRITICAL WORKERS is asymptomatic, the worker is not stood down Medical criteria for fitness for duty are outlined but referred for stress ECG using the Bruce in the tables commencing on page 33. protocol. The exercise capacity should be ≥ 90% of the age/sex predicted capacity (Bruce Standards for chronic disorders are made with et al 1973). the presumption that the disorder is stable and well controlled. If this is not the case, a If the worker is symptomatic, or if there is specialist consultation should be conducted. significant clinical information such as a Fitness for Duty Subject to Review may be marked family history, or the risk score is ≥ 32 recommended after initial assessment by an (when the probability of a coronary event in appropriate specialist. the next five years is near 25%, that is, 5% pa), the worker should be classed Temporarily Cardiac Risk Score: (NB only for High Unfit for Duty and referred for stress ECG. Level Safety Critical Workers) Where stress ECG is positive or clinical These medical standards have adopted the assessment warrants it, referral to a Cardiac Risk Score based on data from the cardiologist should be made for further American Heart Association (Heart to Heart assessment and advice on management. www.med-decisions.com) and developed by Civil Aviation Safety Authority (CASA). The Where the risk score is less than 21 or stress Cardiac Risk Score enables an estimation of ECG is negative, the worker should be the risk of a heart attack over five years and advised regarding any risk factors identified considerably enhances the power of the eg raised blood pressure, smoker etc, and Safety Critical Worker Health Assessment. referred to their general practitioner and other The Heart to Heart web site provides a appropriate programs. calculator for the score and also shows the Although the medical and surgical treatment reduction in score to be obtained if risk factors of 1 may lead to alleviation of symptoms and are successfully modified. This can assist in improved life expectancy, coronary patient education. arteriosclerosis tends to be a progressive Some groups of Safety Critical Workers (eg process and the risk of heart attack, collapse train drivers, operating on the commercial and sudden loss of consciousness is greater network) have duties with high levels of risk than in healthy populations. When assessing on assessment. They are categorised as a patient with cardiovascular disease, the High Level Safety Critical Workers and are health professional should consider any required to have their Cardiac Risk Scores symptoms of sufficient severity to be a risk evaluated as described below and as while performing Safety Critical Work. summarised in the flow chart overleaf.
Code of Practice for Health Assessment of Rail Safety Workers 29 MANAGEMENT OF CARDIAC RISK SCORE
Calculate Cardiac Risk Score
< 21 22 – 31 ≥ 32
Providing asymptomatic, may continue Cease SCW while investigated SCW/drive • Temporarily unfit for duty • Fit for duty subject to review
Stress ECG
Negative Positive
Do risk factors need Refer to Cardiologist modification eg BP ↑, smoker? • Temporarily unfit for duty No Yes
• Fit for duty Refer to GP Manage as appropriate • Fit for duty subject to review
Suspected Angina Pectoris Where chest Anti-coagulant therapy may be used for pains of uncertain origin are reported, every disorders of cardiac rhythm, following valve attempt should be made to reach a positive replacement or for deep venous thrombosis diagnosis and the patient counselled in the to lessen the risk of emboli. However, if not meantime to restrict his or her Safety Critical adequately controlled there is a risk of Work. Generally it would be wise to classify bleeding which in the case of an intracranial the person as Temporarily Unfit for Duty until bleed may acutely affect Safety Critical investigations exclude heart disease. If the Work. Such workers may only work if well tests are positive or the person remains controlled and subject to review. symptomatic and requires anti-angina medication for the control of symptoms, the Hypertension is associated with increased criteria listed for proven angina pectoris risk of heart attack and stroke which is apply. particularly important in High Level Safety Critical Workers. Patients found to have Cardiac surgery may be performed for blood pressure treated or untreated various reasons including valve replacement, consistently greater then 200/110 pose an excision of atrial myxoma or correction of unacceptable risk and should be classed septal defects. In some cases this is curative Temporarily Unfit for Duty and referred for of the underlying disorder. Refer Table 3 on treatment. Patients with blood pressure less Non-working Periods. In other cases the than 200/110 but greater than 150/95 condition may not be stabilised and hence (treated or untreated) may be classed as Fit needs to be individually assessed. All for Duty Subject to Review after other risk cardiac surgery patients should be advised factors have been taken into account. regarding returning to Safety Critical Work in the short-term as for any other post-surgery Effects of Safety Critical Work on the patient and may be classed as Temporarily Heart A further problem in those who have Unfit for Duty. established ischaemic heart disease is that Safety Critical Work such as driving causes Deep venous thrombosis may occur in occasional emotional and sensorimotor association with surgery or from clotting arousal leading to a faster heart rate and disorders. A risk to Safety Critical Work fluctuation in blood pressure. Such workers occurs if a pulmonary embolus arises. DVT may need to respond to emergency which need to be assessed with regard to the theoretically could trigger angina, or even likelihood of recurrence over a long period to infarction. gauge the impact on fitness for duty. A DVT arising in the course of surgery is unlikely to Non-Work Periods. A number of have impact on fitness for duty, because it is cardiovascular incidents and procedures may self-limiting. Treatment often involves anti- impact on short-term Safety Critical Work coagulants and this section in the standard capacity as well as long-term fitness for duty, should also be referred to. for example, AMI or aneurysm repair. Such
30 Department of Infrastructure
situations present an obvious risk. The The recommendations regarding fitness for patient should be classified as Temporarily duty should be considered once the condition Unfit for Duty and should not undertake has stabilised and work capacity can be Safety Critical Work for the appropriate assessed per the standards outlined in this period, as laid out in the following table. chapter.
Table 3. Suggested Non-working Periods Post Cardiovascular Events or Procedures
Event / Procedure Minimum non- working period for Safety Critical Workers Acute Myocardial Infarction 3 months Aneurysm Repair 3 months Angioplasty 4 weeks Cardiac Arrest As determined by treating specialist Cardiac Defibrillator N/A Cardiac Pacemaker Insertion 1 month Coronary Artery By-pass Grafts 3 months Deep Vein Thrombosis As determined by treating specialist Heart/ Lung Transplant 3 months Pulmonary Embolism As determined by treating specialist Syncope 3 months
Code of Practice for Health Assessment of Rail Safety Workers 31
Table 4. Coronary Heart Disease Risk Factor Prediction Chart (Civil Aviation Safety Authority)
1. Find Points For Each Risk Factor Age (If Female) Age (If Male) HDL- Cholesterol Total-Cholesterol Systolic Blood Pressure Other Pts Age Pts Age Pts Age Pts Age Pts HDL-C Pts Total-C SBP Pts 30 -12 47-48 5 30 -2 57-59 13 0.65-0.68 7 3.60-3.99 -3 98-104 -2 Cigarettes 4 31 -11 49-50 6 31 -1 60-61 14 0.69-0.76 6 4.00-4.30 -2 105-112 -1 Diabetic-male 3 32 -9 51-52 7 32-33 0 62-64 15 0.77-0.84 5 4.31-4.60 -1 113-120 0 Diabetic-female 6 33 -8 53-55 8 34 1 65-67 16 0.85-0.90 4 4.70-5.19 0 121-129 1 ECG-LVH 9 34 -6 56-60 9 35-36 2 68-70 17 0.91-0.99 3 5.20-5.69 1 130-139 2 35 -5 61-67 10 37-38 3 71-73 18 1.00-1.09 2 5.70-6.19 2 140-149 3 36 -4 68-74 11 39 4 74 19 1.10-1.19 1 6.20-6.79 3 150-160 4 0 pts for each NO 37 -3 40-41 5 1.20-1.30 0 6.80-7.49 4 161-172 5 38 -2 42-43 6 1.31-1.43 -1 7.50-819 5 173-185 6 39 -1 44-45 7 1.44-1.56 -2 8.20-8.55 6 40 0 46-47 8 1.57-1.70 -3 41 1 48-49 9 1.71-1.89 -4 42-43 2 50-51 10 1.90-2.07 -5 44 3 52-54 11 2.08-2.25 -6 45-46 4 55-56 12 2.26-2.49 -7
2. Sum Points For All Risk Factors Age ( ) + HDL-C ( ) + Total C ( ) + SBP ( ) + Smoker ( ) + Diabetes ( ) + ECG-LVH ( ) = Point Total ( ) NOTE: Minus points subtract from total
3. Look up risk corresponding to point total 4. Compare to Average 10 Year Risk Probability (%) Probability (%) Probability (%) Probability (%) Probability (%) Pts 5Yr. 10Yr. Pts 5Yr. 10Yr. Pts 5Yr. 10Yr Pts 5Yr. 10Yr Age Women Men < 1 <1 <2 10 2 6 19 8 16 28 19 33 30-34 <1 3 2 1 2 11 3 6 20 8 18 29 20 36 35-39 <1 5 3 1 2 12 3 7 21 9 19 30 22 38 40-44 2 6 4 1 2 13 3 8 22 11 21 31 24 40 45-49 5 10 5 1 3 14 4 9 23 12 23 32 25 42 50-54 8 14 6 1 3 15 5 10 24 13 25 55-59 12 16 7 1 4 16 5 12 25 14 27 60-64 13 21 8 2 4 17 6 13 26 16 29 65-69 9 30 9 2 5 18 7 14 27 17 31 70-74 12 24 Modified from Chart by The American Heart Association, April 2002
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MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES
CONDITION CRITERIA Acute Myocardial The person should not drive/perform Safety Critical Work for at least three months after Infarct an AMI. See also The criteria for Fit for Duty are not met: Angioplasty • If the person has had an acute myocardial infarction. See also Coronary Fit for Duty Subject to Review may be recommended, taking into account the opinion of Artery Bypass a cardiologist, and the nature of the work: Grafting (CABG) • At least 3 months after an uncomplicated AMI; • If the clinical history is one of minimal symptoms; and 1. If a Bruce Treadmill Test (or equivalent protocol) of greater than 9 minutes (men) and 6 minutes (women) and thallium or sestamibi scan show no evidence of myocardial ischaemia. 2. If myocardial ischaemia is demonstrated a coronary angiogram may be offered. If that shows lumen diameter reduction of less than 70% in a major coronary branch, and less than 50% in the left main coronary artery, the person may perform Safety Critical Work, subject to annual review. 3. If the result of the angiogram shows a lumen diameter reduction of equal to or greater than 70% in a major coronary branch and less than 50% in the left main coronary artery (or if an angiogram is not conducted), Fit for Duty Subject to Review may be recommended: • If the clinical history is one of minimal symptoms; and • The exercise capacity is ≥ 90% of the age/sex predicted capacity on the Bruce Treadmill Test (or equivalent protocol); and • There is no evidence of severe ischaemia, that is, less than 2mm ST segment depression on an exercise ECG and absence of a large defect on a stress perfusion scan; and • There is an ejection fraction of 40% or over. The presence of other risk factors should also be considered.
Aneurysms The person should not drive/perform Safety Critical Work for at least three months post Abdominal and repair. Thoracic The criteria for Fit for Duty are not met:
• If the person has aortic aneurysm, thoracic or abdominal. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: • At least 3 months after repair; • If the condition is minor; or • If the condition has been adequately treated.
Angina The criteria for Fit for Duty are not met: • If the person is subject to angina pectoris. Fit for Duty Subject to Periodic Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work, in the following circumstances: 1. If the exercise capacity is ≥ 90% of the age/sex predicted capacity on the Bruce Treadmill Test (or equivalent protocol) and thallium or sestamibi scan show no evidence of myocardial ischaemia. (cont)
Code of Practice for Health Assessment of Rail Safety Workers 33
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES
CONDITION CRITERIA Angina 2. If myocardial ischaemia is demonstrated a coronary angiogram may be offered. If that shows lumen diameter reduction of less than 70% in a major coronary branch, (continued) and less than 50% in the left main coronary artery, the person may perform Safety Critical Work, subject to annual review. 3. If the result of the angiogram shows a lumen diameter reduction of equal to or greater than 70% in a major coronary branch and less than 50% in the left main coronary artery (or if an angiogram is not conducted), Fit for Duty Subject to Review may be recommended: • If the clinical history is one of minimal symptoms; and • There is an exercise tolerance of greater than 9 minutes (men) and 6 minutes (women) on the Bruce Treadmill Test (or equivalent protocol); and • There is no evidence of severe ischaemia, that is, less than 2mm ST segment depression on an exercise ECG and absence of a large defect on a stress perfusion scan; and • There is an ejection fraction of 40% or over. The presence of other risk factors should also be considered. Where surgery or angioplasty is undertaken to relieve the angina, the criteria listed in the table below apply.
Angioplasty The person should not drive/perform Safety Critical Work for at least four weeks after the angioplasty. The criteria for Fit for Duty are not met: If the person has had coronary angioplasty Fit for Duty Subject to Periodic Review may be recommended, taking into account the opinion of a cardiologist and the nature of the work: • At least 4 weeks after the angioplasty; • If the clinical history is one of minimal symptoms; and • There is an exercise tolerance of greater than 9 minutes (men) and 6 minutes (women) on the Bruce Treadmill Test (or equivalent protocol); and • There is no evidence of severe ischaemia, that is, less than 2mm ST segment depression on an exercise ECG and absence of a large defect on a stress perfusion scan; and • There is an ejection fraction of 40% or over.
Anti-coagulant The criteria for Fit for Duty are not met: therapy • If the person is on anti-coagulant therapy. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist or haematologist, and the nature of the work: • If the therapy is satisfactory.
Arrhythmia The criteria for Fit for Duty are not met: • If the person has a history of recurrent or persistent arrhythmia, which may result in syncope or incapacitating symptoms. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: • If the condition has been cured surgically (for example, Wolff-Parkinson White syndrome); or • If the condition has been successfully treated medically for at least three months. If the person is taking anti-coagulants refer to anti-coagulants therapy above.
34 Department of Infrastructure
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES
CONDITION CRITERIA Cardiac Arrest The non-working period following a cardiac arrest should be determined by the treating specialist. The criteria for Fit for Duty are not met: • If the person has suffered a cardiac arrest. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: following an appropriate non-working period, and depending on the cause of the cardiac arrest and response to treatment.
Cardiac Risk The criteria for Fit for Duty are not met: Score • If the person has a cardiac risk score of 22 or greater. For subsequent management refer to text and flow chart.
Cardiac The criteria for Fit for Duty are not met: Defibrillator • If the person has a cardiac-defibrillator implanted for ventricular arrhythmias. (AICD) Cardiac The person should not drive/perform Safety Critical Work for at least one month after Pacemaker insertion of pacemaker. The criteria for Fit for Duty are not met: • If a cardiac pacemaker is required. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist with expertise in electrophysiology, and the nature of the work: • At least 1 month after insertion of the cardiac pacemaker After consideration of the relative risks of pacemaker dysfunction (see also Cardiac Defibrillator).
Congenital The criteria for Fit for Duty are not met: Disorders • If the person has a complicated congenital heart disorder. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: • If there is a minor congenital heart disorder such as pulmonary stenosis, atrial septal defect, small ventricular septal defect, bicuspid aortic valve, patent ductus arteriosus or mild coarctation of the aorta; and • There are no other disqualifying conditions.
Coronary Artery The person should not drive/perform Safety Critical Work for at least three months after Bypass Grafting CABG. (CABG) The criteria for Fit for Duty are not met: • Following CABG. Fit for Duty Subject to Periodic Review may be recommended, taking into account the opinion of a cardiologist and the nature of the work: • At least 3 months after CABG, and • There is minimal residual musculoskeletal pain after the chest surgery, and • If the clinical history is one of minimal symptoms; and • If the exercise capacity is ≥ 90% of the age/sex predicted capacity on the Bruce Treadmill Test (or equivalent protocol); and • There is no evidence of severe ischaemia, that is, less than 2mm ST segment depression on an exercise ECG and absence of a large defect on a stress perfusion scan; and • There is an ejection fraction of 40% or over. The presence of other risk factors should also be considered.
Code of Practice for Health Assessment of Rail Safety Workers 35
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES
CONDITION CRITERIA Deep Vein The non-working period following DVT should be determined by the treating specialist. Thrombosis (DVT) The criteria for Fit for Duty are not met: • If the person suffers deep vein thrombosis which is liable to recurrence or embolus. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist and the nature of the work: • Following an appropriate non-working period; and • Depending on the cause of the thrombosis and the response to treatment.
Dilated The criteria for Fit for Duty are not met: Cardiomyopathy • If the person has a dilated cardiomyopathy. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: • If the ejection fraction is greater than 40%.
ECG Changes: An ECG is only required if clinically indicated. Strain Patterns, The criteria for Fit for Duty are not met: Bundle Branch • If the person has an electrocardiographic abnormality, for example left bundle branch block, pre-excitation or changes suggestive of myocardial ischaemia or Blocks or Heart previous myocardial infarction. Block Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: • If the condition has been cured surgically; or • If the condition has been successfully treated medically for at least 3 months; or • There is an exercise tolerance of greater than 9 minutes (men) and 6 minutes (women) on the Bruce Treadmill Test (or equivalent protocol); and • There are no other disqualifying conditions.
Heart Failure The criteria for Fit for Duty are not met: • If the person has heart failure. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: • If there is an exercise tolerance of greater than9 minutes (men) and 6 minutes (women) on the Bruce Treadmill Test (or equivalent protocol); and • There is an ejection fraction of 40% or over; and • There is a satisfactory response to treatment; and • The underlying cause of the heart failure is considered.
Heart/Lung The person should not drive/perform Safety Critical Work for at least three months post- Transplant transplant. The criteria for Fit for Duty are not met: • If the person has had a heart or heart/lung transplant. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a transplant cardiologist, and the nature of the work.
36 Department of Infrastructure
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES
CONDITION CRITERIA Hypertension The criteria for Fit for Duty are not met: • If the person’s sitting blood pressure is consistently 200/110 or greater (treated or untreated); or • If there is end organ damage (cardiac, cerebral, or retinal) which will impair safe working; or • If treatment results in marked postural hypotension or impaired alertness. The presence of other risk factors should also be considered. Classify Temporarily Unfit for Duty until fully assessed and treatment is satisfactory. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: • If the person is treated with anti-hypertensive drug therapy and effective control of hypertension is achieved (ideal blood pressure less than 140/90 but no greater than 150/95) without appreciable side effects over a four week follow-up period; and • If there is no evidence of damage to target organs relevant to Safety Critical Work, or associated ischaemia, or other forms of heart disease; and • If causative factors have been treated.
Hypertrophic The criteria for Fit for Duty are not met: Cardiomyopathy • If the person has HCM. (HCM) Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: • If the person is asymptomatic; and • The left ventricular ejection fraction is >40; and • If the exercise capacity is ≥ 90% of the age/sex predicted capacity on the Bruce Treadmill Test (or equivalent protocol) without significant cardiac symptoms or significant ST segment (>2mm) shift; and • An absence of severe LV hypertrophy, a family history of sudden death, or ventricular arrhythmia on Holter testing.
Pulmonary The non-working period following pulmonary embolism should be determined by the Embolism treating specialist. The criteria for Fit for Duty are not met: • If the person has suffered a pulmonary embolism. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work: • Following an appropriate non-working period; and • Depending on the cause of the embolus and response to treatment.
Stroke See Neurological Disorders.
Syncope due to The person should not drive/perform Safety Critical Work for at least three months Hypotension after syncope. (Vasovagal and The criteria for Fit for Duty are not met: autonomic • If the condition is severe enough to cause episodes of loss of consciousness dysfunction) without warning. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work depending on: • Identification of the underlying cause; and/or • The institution of satisfactory treatment.
Code of Practice for Health Assessment of Rail Safety Workers 37 MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES
CONDITION CRITERIA Valvular Heart The criteria for Fit for Duty are not met: Disease • If the person has any history or evidence of valve disease, with or without surgical repair or replacement, association with symptoms or a history of, embolism, arrhythmia, cardiac enlargement (on chest X-ray greater than 16cm), abnormal ECG, high blood pressure; or • If the person is taking anti-coagulants. Fit for Duty Subject to Review may be recommended noting the criteria specified above in relation to anti-coagulant therapy; or • If mitral stenosis is present with echocardiograph evidence of moderate (valve area <1.5cm2) or severe stenosis. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: • If the person’s cardiological assessment shows mild valvular disease of no haemodynamic significance, and there is no other cardiac condition per this Code which would render the person unfit to drive/perform Safety Critical Work; or • Three months following successful surgery and there is no other cardiac condition per this Code which would render the person unfit to drive/perform Safety Critical Work.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further Reading Akiyama, T., et al, Resumption of driving after life-threatening Li, H., et al, Potential risk of vasovagal syncope for motor ventricular tachyarrhythmia, New England Journal of Medicine, vehicle driving, The American Journal of Cardiology, 85(2), 345(6), 391-397, 2001. 184-186, 2000. Bruce R A , Kusumi F ,Hosmer D,Maximal oxygen intake and Lurie, K.G., et al, Resumption of motor vehicle operation in nomographic assessment of functional aerobic impairment in vasovagal fainters, The American Journal of Cardiology, 83(4), cardiovascular disease. Am Heart J 85: 546-562, 1973. 604-606, 1999. Cardiovascular Disease and Driving www.csanz.edu.au Petch, M.C., Driving and heart disease, European Heart Journal, 19(8), 1165-77, 1998.
38 Department of Infrastructure
5. DIABETES
5.1 RELEVANCE TO SAFETY CRITICAL Impairment of consciousness and judgment WORK may develop rapidly and result in the loss of control of a train or tram. Hypoglycaemic Diabetes may affect the ability to perform awareness is an important consideration. Safety Critical Work due to sudden loss of Patients with long standing diabetes can have concentration and loss of ability to control “hyperglycaemic unawareness”, whereby they machinery. This is particularly relevant to receive no early warning symptoms of low Category 1 High Level Safety Critical blood glucose levels and can go straight into Workers but confusion may also affect the more severe stage of brain and nervous judgement that is relevant to both system dysfunction, although the changes can Category 1and2 Safety Critical Workers. be very subtle initially. Individuals who are Diabetes may affect a person’s ability to known to them, such as family members, perform Safety Critical Work, either through often recognise the initial stages of a slight loss of consciousness in a hypoglycaemic mood change or impaired judgement or a little episode or from end organ effects on relevant clumsiness, in an insulin dependent diabetic, functions, including effects on vision, the and recognise this as an early hypoglycaemic heart, the peripheral nerves and vasculature warning. of the extremities particularly the feet. When assessing a worker with insulin The main hazard in Safety Critical Workers dependent diabetes an annual report from the with insulin requiring diabetes is the patient’s general practitioner, or an unexpected occurrence of hypoglycaemia. independent specialist physician or endocrinologist is recommended. The report should include details of general health, 5.2 MEDICAL CRITERIA FOR SAFETY indication of satisfactory diabetes control and CRITICAL WORKERS freedom from severe complications. The frequency of any mild hypoglycaemic attacks Medical criteria for fitness for duty are outlined and of any significant hypoglycaemia should in the table overleaf. be recorded. Recommendations should be For diabetes-related end organ damage, for made about any further education including example diabetic retinopathy, see the Vision blood glucose awareness training (BGAT) and and Eye Disorders chapter. management required. Adequacy of control may be assessed by It is sometimes important to interview family tests including glycosylated haemoglobin. members, as diabetics are often reluctant to admit they have been suffering from Hypoglycaemia hypoglycaemic episodes as they are clearly aware of their significance in terms of their A defined hypoglycaemic event relevant to employability. If an individual is subject to lack Safety Critical Work is one of sufficient of awareness of hypoglycaemic severity to cause impairment of perception, of symptomatology, then they are unsuitable for motor skills or consciousness, or abnormal working roles in which they are responsible for behaviour. It is to be distinguished from mild Safety Critical Work. hypoglycaemic symptoms such as sweating, tremulousness, hunger and tingling around The worker who has a defined hypoglycaemic the mouth which are common occurrences in episode or experiences a hypoglycaemic the life of a person with diabetes treated with episode experienced whilst working should be insulin and some hypoglycaemic agents. classified as Temporarily Unfit for Duty and should not perform Safety Critical Work until Diabetics are trained to aim for lower glucose they have been cleared by the specialist. levels in order to prevent long-term end organ damage due to hyperglycaemia. This The worker should also be advised to take presents a challenge for managing workers to appropriate precautionary steps to avoid minimise risk of hypoglycaemia. hypoglycaemic episodes, for example: Hypoglycaemia syndrome is also more • self monitoring of blood glucose levels; common nowadays with Humalogue insulin preparations, and is difficult to recognise • carrying of glucose in the vehicle; particularly in the early stages. • compliance with specified review periods (general practitioner or specialist); and Hypoglycaemia may be caused by many factors including non-compliance or alteration • cessation of Safety Critical Work should a to medication, unexpected exertion or hypoglycaemic episode occur. irregular meals. Irregular meals may be an In the case of a hypoglycaemic episode, if the important consideration with long distance diabetic person is conscious and able to operation or those operating on shifts.
Code of Practice for Health Assessment of Rail Safety Workers 39 swallow, administration of sugar or honey or Job modification such as altered rosters to sweet drinks or any digestible carbohydrate is help with stability of control or two person indicated. If uncooperative or drowsy or crews may be considered. unconscious the patient will need either intramuscular glucagon injection or intravenous dextrose in order to be resuscitated.
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – DIABETES
CONDITION CRITERIA Diabetes A person with Diabetes controlled by diet alone may perform Safety Critical Work. controlled by diet They should be reviewed periodically regarding progression of the illness. alone Non-Insulin The criteria for Fit for Duty are not met: Requiring Type 2 • If the person has Non-Insulin Requiring Diabetes Mellitus on oral hypoglycaemic Diabetes Mellitus agents. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in Diabetes or Endocrinology, and the nature of the work: • If the condition is well controlled and the patient compliant with treatment; and • There is an absence of defined hypoglycaemic episodes as assessed by the specialist, and • The patient has awareness (sensation) of hypoglycaemia, and • The patient is taking agents that provide the minimum risk of hypoglycaemia; and • There is an absence of end organ effects that may affect working per this Code.
Insulin-Requiring The criteria for Fit for Duty are not met: Diabetes Mellitus • If the person has Insulin Requiring Diabetes Mellitus. (both Types 1 and 2) Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in Diabetes or Endocrinology, and the nature of the work (avoidance of collapse is particularly important in Category 1 tasks):
• If the condition is well controlled and the patient compliant with treatment; and
• There is an absence of defined hypoglycaemic episodes as assessed by the specialist, and
• The patient has awareness (sensation) of hypoglycaemia, and
• The patient is taking agents that provide the minimum risk of hypoglycaemia; and • There is an absence of end organ effects that may affect working per this Code. Fitness for duty subject to job modification, such as altered rosters or two person crews may be considered. In the event of a defined hypoglycaemic episode occurring in a previously well- controlled person they should be immediately classed Temporarily Unfit for Duty, and should not drive/perform Safety Critical Work for a period determined by a specialist.
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Temporary Illnesses. This Code does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms, which could have implications for their job, but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References
NHMRC, Diabetes and driving, Canberra, 1992
Further reading Cox, D.J., et al, Progressive hypoglycemia’s impact on driving Laberge-Nadeau, C., et al, Impact of diabetes on crash risks simulation performance. Occurrence, awareness and of truck-permit holders and commercial drivers, Diabetes correction, Diabetes Care, 23(2), 163-170, 2000. Care, 23(5), 612-617, 2000. Qualifying individuals with insulin-treated diabetes to operate commercial motor vehicles, Federal Motor Carrier Safety MacLeod, K.M., Diabetes and driving: towards equitable, Administration, Washington DC, November 2001. evidence-based decision-making, Diabetic Medicine, 16(4), 282-290, 1999
Weinger, K., et al, The perception of safe driving ability during hypoglycemia in patients with type 1 diabetes mellitus, The American Journal of Medicine, 107(3), 246-253, 1999.
Code of Practice for Health Assessment of Rail Safety Workers 41 6. DRUGS – ILLICIT See also Part 5, Drug and Alcohol Controls, for summary of relevant legislation
6.1 RELEVANCE TO SAFETY CRITICAL Effect of Drugs on Rail Safety Work WORK Illicit drugs are by their nature psychoactive (or psychotropic). This means their Drug Impairment Legislative Requirements detrimental effects in safety terms are not Many of the physiological effects of illicit drugs limited to their demonstrated physiological are similar to both alcohol and psychoactive effects on the workers physical skills, but prescription drugs. Their usage is therefore extend to their psychological, or behavioural likely to cause a significant safety hazard to effects. Those under the influence of these Safety Critical Work. This is particularly so drugs have a higher propensity to behave in a where illicit drugs are used in combination manner incompatible with safe working. This with prescription drugs or alcohol. may involve but not be limited to, risk taking, aggression, feelings of vulnerability, narrowed All states and territories therefore require attention and poor judgement. accredited rail organistions to ensure that rail safety workers are not affected by drugs when Information regarding effects of stimulants on performing rail safety duties. In Victoria, in risk of accidents mainly comes from road June 2002, the Transport Act 1983 was crash data. Stimulant drugs such as amended to provide for controls over the use amphetamines and cocaine, which produce a of drugs by rail safety workers. The new laws heightened sense of well being, uninhibited are in addition to existing laws for alcohol behaviour, increased aggression and risk control and rail organisation’s policies which taking behaviours obviously have a potential necessitate a zero blood-alcohol for causing accidents. These drugs have concentration. They make it an offence to been used to combat fatigue and while they undertake rail safety work while impaired by may initially increase alertness and efficiency, any type of drug. their effect is notoriously unpredictable and may be accompanied by marked changes in The Act defines a drug broadly as: mood and behaviour. The use of illicit (and licit) stimulants to counteract the effects of any substance - - - that may fatigue carries with it the risk of fatigue temporarily or permanently deprive a rebound. This is observed when the effect of person of any of his or her normal the drug wears off and is associated with mental or physical faculties. It may profound sleepiness, which can result in a be a substance in any form, whether driver suddenly falling asleep at the wheel, gaseous, liquid, solid or other and with obvious consequent risk of accident. includes material, preparation, extract and admixture. There is little information about safety critical work such as driving and the short or long- Illicit drugs of concern are those prohibited by term effects of drugs such as LSD, heroin and the Drugs, Poisons and Controlled designer drugs (for example, Ecstasy, Angel Substances Act 1981. These include Dust), and no information specifically relevant cannabis in its various forms, non-prescribed to rail safety. However, the known clinical opiates, such as heroin, non-prescribed effects of these drugs indicate that they have amphetamines or speed, and designer drugs adverse effects on driving skills and judgment. such as ecstasy and cocaine. Given their significant affect on mood and This Code of Practice supports alcohol and behaviour, their use is clearly not compatible drug policies through the provision of advice with safety critical work. to authorised health professionals regarding Cannabis can impair psychomotor functions the management of suspected impairment at related to safety critical skills and has been the time of health assessment and the shown to have adverse effects on driving skills interpretation of drug screen results. However and judgment. However, there is still debate specific procedures for drug and alcohol about the duration of impairment outside screening are beyond the scope of this laboratory experiments. standard. Methadone abuse is not compatible with The authorised health professional should safety critical work. However, it is recognised acquaint themselves with the relevant that Methadone may be prescribed for legislation and the procedures of the narcotic addiction and in some circumstances organisation for which they provide services. such persons may be recommended Fit for Screening should be conducted in line with Duty Subject to Review. Australian/New Zealand Standard 4308:2001: Procedures for the Collection, Detection and The combination of alcohol with illicit drugs is Quantification of Drugs of Abuse in Urine. especially dangerous.
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6.2 MEDICAL CRITERIA FOR SAFETY abnormal or uncharacteristic signs in relation CRITICAL WORKERS to speech, eyes, breathing, skin, actions, movement, balance, attitude and Medical criteria for fitness for duty are outlined comprehension, this should be discussed with in the table overleaf. the worker. Careful individual assessment must be made Where no satisfactory medical basis for of workers using illicit psychoactive drugs. impairment is established, (that is, a Additional advice from those involved in prescription medication or OTC drug taken for specialised treatment centres will frequently a defined purpose, or a medical condition) the be necessary and ongoing assessment is worker should be classified as Temporarily likely to be crucial, including blood tests. Unfit for Duty Subject to Review. Patients with ‘dual diagnosis’ in particular may Management should be contacted and require specialist assessment regarding advised that the person has impairment for working. which no medical basis could be found. Management will then direct the steps to be Users of illicit drugs are unlikely to volunteer taken which may include a drug screen. This information about their condition. This creates is illustrated in Diagram 7. a problem in identifying cases of illicit drug use. Interpretation of drug screen results is a difficult area and referral to a doctor who The habitual use of illicit drugs is not tolerated specialises in reviewing positive results may in rail safety work. Occasional use of these be appropriate in some cases. The most drugs requires very careful assessment. common illicit drug detected is cannabis and Some companies may have a policy of its metabolites. Generally a level of 50ng/mL counselling or disciplining the worker who is on GCMS is considered to be positive but this found to have an isolated case of drug use. can be difficult to interpret because of the long The health professional should be aware of half life of cannabis and also because the the organisation’s policy in this regard. detected level does not necessarily Screening for illicit drugs is routinely required correspond to the level of impairment. for Pre-placement (Transfer or Change of Nevertheless, the impact of cannabis use on Grade) Health Assessments. the functioning of the rail safety worker’s decision-making process cannot be Screening for illicit drugs is not routinely underestimated. intended at the Periodic Health Assessment, but may be required by management at a Other illicit drugs such as heroin, cocaine and Triggered Health Assessment. MDMA are less commonly found on drug screen because of their shorter half-lives and If during a Periodic Health Assessment, the their relatively less common usages. A health professional has a reasonable belief positive result for morphine on urinary that the worker may be impaired by a drug analysis cannot be extrapolated to heroin use. (prescribed or illicit), based on observation of
Diagram 7. Periodic Health Assessment - Management of possible impairment due to alcohol or drugs (illicit and prescription/OTC) Is there evidence of impairment? Preliminary Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, attitude, comprehension). YES NO
Discuss with worker. No further action Is there a medical basis for impairment, ie prescription (continue with health medication /OTC drug taken for a defined purpose. assessment) YES NO
Medical basis If alcohol or illicit drug use suspected: • Classify Temporarily Unfit for Duty. • Classify Temporarily Unfit for Duty and advise on • If appropriate, discuss medication with report impairment without clear medical basis. GP/treating doctor in order to resolve impact on • Contact employer regarding impairment without employment. clear medical basis and await further instructions • If appropriate, refer to relevant chapter for from employer. medical conditions. • Identify review period.
Code of Practice for Health Assessment of Rail Safety Workers 43 MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – DRUGS – ILLICIT
CONDITION CRITERIA Impairment The criteria for Fit for Duty are not met: due to illicit • If the worker is impaired by illicit drug/s drugs Refer Diagram 7 for management.
Illicit drugs The criteria for Fit for Duty are not met: Narcotics, • If there is evidence of illicit drug use or dependence. Analgesic Fit for Duty Subject to Review may be recommended taking into account the opinion of an abuse, appropriate specialist and the nature of the work (note: avoidance of sudden incapacity is Methadone particularly important in Category 1 tasks): (illicit use), and other illicit drug • For persons who are compliant with treatment for illicit drug addiction (including use methadone or buprenorphine medication); and • The severity of the addiction(s), the response to treatment and the working requirements are taken into account. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work where amphetamines/stimulants are prescribed for a medical condition, for example, ADHD.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further reading Liguori, A., Gatto, C.P., Robinson, J.H., Effects of marijuana on equilibrium, psychomotor performance, and simulated driving, Behavioral Pharmacology, 9(7), 599-609, 1998.
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7. DRUGS – PRESCRIPTION AND OVER THE COUNTER (OTC). See also Part 5, Drug and Alcohol Controls, for summary of relevant legislation
7.1 RELEVANCE TO SAFETY possible effects on driving or operating CRITICAL WORK machinery. Deleterious substances are included by Drug impairment and Legislative reference to Section 57 of the Drugs, Poisons Requirements and Controlled Substances Act (1981). This Studies show that common medications, includes methanol, methylated spirits and prescribed for a number of illnesses, including inhaled solvents, resulting from glue and anxiety and depression, can affect work petrol sniffing. performance and increase the likelihood of a This Code of Practice supports alcohol and rail incident. drug policies through the provision of advice All states and territories therefore require to authorised health professionals regarding accredited rail organistions to ensure that rail the management of suspected impairment at safety workers are not affected by drugs when the time of health assessment and the performing rail safety duties. In Victoria, in interpretation of screening results. However June 2002 the Transport Act 1983 was specific procedures for drug and alcohol amended to provide for controls over the use screening are beyond the scope of this of drugs by rail safety workers. The new laws standard. are in addition to existing laws for alcohol The authorised health professional should control and rail oranisation’s policies which acquaint themselves with the relevant necessitate a zero blood-alcohol concentration. legislation and the procedures of the They make it an offence to undertake rail organisation for which they provide services. safety work while impaired by any type of Screening should be conducted in line with drug. Australian/New Zealand Standard 4308:2001: The Act defines a drug broadly as: Procedures for the Collection, Detection and Quantification of Drugs of Abuse in Urine. any substance - - - that may temporarily or permanently deprive a person of any of his or her normal 7.2 GENERAL MANAGEMENT mental or physical faculties. It may GUIDELINES be a substance in any form, whether gaseous, liquid, solid or other and In all cases when health professionals are includes material, preparation, extract prescribing or dispensing medications and admixture. (including OTC and alternative medications), they should consider any possible effects on The Minister for Transport has declared safe working skills and advise the worker on certain substances to be a drug for the what they should do to avoid impairment. purposes of the Act and has published a list of Failure to do so may have medico-legal drugs in the Government Gazette. (See Part consequences for the health professional in 5). the event of a rail incident involving the The list does not contain banned substances. patient. Rather, it includes drugs that have been Prescribing or dispensing of any drug for the proven to show that given particular first time should be accompanied by a general circumstances, impairment may be caused. warning to the patient to be vigilant for Its primary purpose is to provide prima facie responses that may affect ordinary activities evidence in a Court of Law in proving that a including safety critical work. A similar particular drug has the ability to cause warning should accompany changes in dose, impairment. Drugs included on the scheduled or the addition of other drug treatment. list are: Problems affecting fitness for rail safety work • Drugs of dependence as defined in may arise with short-term use of drugs when Section 4 of the Drugs, Poisons and the condition being treated does not itself Controlled Substances Act (1981) and preclude working, for example, drowsiness listed in Schedule 11 of that Act. due to (older generation) antihistamines for • Drugs listed in Schedule K of the hay fever. The subjective effects of the drug Standard Uniform Schedule for Drugs and should be determined by a test dose before Poisons. These are incorporated into the working is attempted. Drugs, Poisons and Controlled Substances Act (1981) by reference as Legitimate long-term medication for therapy or the 'Commonwealth Standard' and are prophylaxis should not automatically preclude substances which require a warning as to fitness for duty. But many drugs can diminish their potential to cause drowsiness and the capacity for performing rail safety work
Code of Practice for Health Assessment of Rail Safety Workers 45 safely in addition to any such effects of the Drug screening is not intended to be a routine disorder being treated. Successful treatment part of the Periodic Health Assessment of rail will often increase safety by control of the safety workers. Drug screening is routinely disorder, for example, effective prevention of required for Pre-placement or Change of seizures. Issues relating to drug treatment of Grade Health Assessments and may be chronic disorders such as epilepsy, psychiatric required at a Triggered Health Assessment. conditions and diabetes are dealt with in the relevant sections devoted to these diseases. If during a Periodic Health Assessment, the health professional has a reasonable belief Workers receiving continuing long term drug that the worker may be impaired by a drug treatment should be evaluated for their (prescribed or illicit), this should be assessed reliability in taking the drugs according to consistent with the procedures for Preliminary directions and their understanding of the Impairment Assessment adopted under the possibility that the effect of the drug may be drug control laws. A reasonable belief that the unexpectedly affected by factors such as drug worker may be impaired by a drug may be interactions. They should also be assessed based on observation of abnormal or for their acceptance that their medicines can uncharacteristic signs in relation to speech, have undesired consequences that may affect eyes, breathing, skin, actions, movement, their ability to work safely. balance, attitude and comprehension. Combined effects of prescribed and OTC Where impairment is suspected, the results medications should also be considered. should be discussed with the worker. If a When such medicine is prescribed or medical basis for possible impairment is dispensed adequate counselling should be established (that is, a prescription medication provided and labelling requirements complied or OTC drug is being taken for a defined with. purpose, or a medical condition), the health professional should classify the worker as There are many useful community information Temporarily Unfit for Duty Subject to Review resources for patients, including the Australian and identify a review date. Where Drug Foundation website appropriate, the worker’s GP may be www.adf.org.au/dd/index.htm. contacted to discuss the impact of their current treatment on their fitness for duty. 7.3 MEDICAL CRITERIA FOR SAFETY Where there is not a satisfactory a medical CRITICAL WORKERS basis for impairment, (that is, a prescription medication or OTC drug taken for a defined Medical criteria for fitness for duty are outlined purpose, or a medical condition), the worker in the table overleaf. should be classified as Temporarily Unfit for Safety Critical Workers are required to take all Duty Subject to Review. The employer should current medication or a list to the health be contacted and advised that the person has assessment appointment for the purposes of impairment for which no medical basis could identifying any potential impact on rail safety be found. The employer will then direct the work. steps to be taken as shown in Diagram 8).
Diagram 8. Drug and Alcohol Impairment Assessment and Management
Is there evidence of impairment? Preliminary Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, attitude, comprehension).
YES NO
Discuss with worker. No further action Is there a medical basis for impairment, ie prescription (continue with health medication /OTC drug taken for a defined purpose. assessment) YES NO
Medical basis If alcohol or illicit drug use suspected:
• Classify Temporarily Unfit for Duty. • Classify Temporarily Unfit for Duty and advise • If appropriate, discuss medication with on report impairment without clear medical GP/treating doctor in order to resolve impact basis. on employment. • Contact employer regarding impairment without • If appropriate, refer to relevant chapter for clear medical basis and await further medical conditions. instructions from employer.
• Identify review period.
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MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – DRUGS – PRESCIPTION & OTC
CONDITION CRITERIA Impairment due to The criteria for Fit for Duty are not met: prescription or • If the person is impaired due to the effects of prescription or OTC drugs. OTC drugs Refer to Diagram 8 for management.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, patients presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References 1. Classification of medicines according to their influence on driving ability. Grenez, M. V. et al. Acta Clin Belg Suppl; 1999; 1; 82-8. 2. Relations among chronic medical conditions, medications, and automobile crashes in the elderly: a population-based case-control study. McGwin, G. Jr et al. Am J Epidemiol; 2000; 152; 424-31. 3. Driving ability in cancer patients receiving long-term morphine analgesia. Vainio, A. et al. Lancet; 1995; 346; 652-3.
Further Reading / Reference Material Austroads report Drugs and Driving in Australia, 1999. British Medical Association website on Driving under the influence of drugs (via www.bma.org.uk) Ogden, E., and Brous, D., Medicines and Driving – A Code of Practice for Health Care Professionals, Report No GR/99-7, 2000. Victorian Parliamentary Road Safety Committee Report, Effects of Drugs (Other than Alcohol) on Road Safety in Victoria 1996.
Code of Practice for Health Assessment of Rail Safety Workers 47 8. EPILEPSY
8.1 RELEVANCE TO SAFETY period of such premonitory symptoms) 13. CRITICAL WORK There are also examples where seizures only occur at a particular time of day, especially in Epilepsy may affect the ability to perform the first hour after awakening. Safety Critical Work due to sudden loss of
concentration and loss of ability to control machinery. This is particularly relevant to 8.2 MEDICAL CRITERIA FOR SAFETY Category 1 High Level Safety Critical Workers CRITICAL WORKERS but post ictal confusion may also affect judgement that is relevant to both Category Medical criteria for fitness for duty are outlined 1and2 Safety Critical Workers. in the table overleaf. Epilepsy is a common disorder with a A confirmed diagnosis of epilepsy will mean cumulative incidence of 2% of the population, that the criteria for fit for duty are not met. with 0.5% affected and taking medication at It is extremely important that the worker’s 5 any one time . Fortunately, the majority of specific epilepsy syndrome and seizure types cases respond well to treatment with a are identified so that an adequate evaluation 5-11 terminal remission rate of 80% or more . of the person’s safety can be undertaken The majority suffer few seizures in a lifetime (including the risk of further seizures) and the and about half will have no further seizures in appropriate therapy instituted. Thus any the first one or two years after starting Safety Critical Worker experiencing a seizure 8-10 treatment . Some cases may eventually or recurrent seizures should be referred to an cease medication and in other selected cases appropriate consultant for detailed evaluation. surgery has proven beneficial. The table recommends seizure-free periods Seizures vary considerably, some being after which resumption of work may be purely subjective experiences, for example, permitted on the advice of a suitably qualified some simple partial seizures but the majority consultant. In considering the recommended involve some impairment of consciousness seizure-free period, the longer period should (for example, absence and complex partial generally be applied, but a shorter period may seizures) or loss of control (for example, focal be accepted on the recommendation of a motor, simple or complex partial or myoclonic physician experienced in the management of seizures). Convulsive (tonic-clonic) seizures epilepsy. Relevant considerations will include may be generalised from onset or secondarily response to treatment, previous seizure generalised with partial onset. Seizures frequency, the nature of seizures, the associated with loss of awareness, even if syndromic diagnosis and the patient’s brief or subtle, or loss of motor control have reliability and compliance with treatment. the potential to impair the ability to perform Further considerations are the duties to be 12,13 Safety Critical Work . performed and the hours to be worked. Information regarding risk of accidents due to In the assessment of worker fitness and epilepsy mainly comes from road crash data. ongoing disease management the following Estimates of the relative casualty crash risk of must be taken into account: drivers with epilepsy compared with other 14-16 • the worker must have been free of drivers has varied from 1.0 to 1.95 , (and 17 seizures for the specified period (see in one exceptional study 7.0 ). Around 11% medical standards below) of crashes of drivers with epilepsy are felt to be seizure-related14. Reported estimates of • the worker must continue to take anti- the prevalence of epilepsy-related crashes epileptic medication regularly when and vary between 0.01% and 0.3% of all crashes2, as prescribed 18, 22 . • the worker should ensure adequate sleep Complex partial seizures without aura, and not drive/work if sleep deprived. secondarily generalised seizures and • the worker should avoid other generalised tonic-clonic seizures are the types circumstances or the use of substances most implicated in road crashes. Simple that are known to increase the risk of partial seizures, complex partial seizures with seizures. aura and absence seizures are less All Safety Critical Workers who need active frequently, and myoclonic seizures are rarely 23 management of epilepsy should be under implicated . Other examples include seizures review, including where necessary, at least that have occurred only during sleep, some, annual specialist appraisal. The use of an but not all, simple partial seizures ('auras'), independent specialist may be considered. and seizures that are consistently preceded by a prolonged warning or premonition The Initial or Isolated Seizure: The (provided that full control is retained during the occurrence of a seizure in a Safety Critical
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Worker warrants consultant assessment. The Recurrent Seizure. In the event of a assessment may reveal that the seizure was recurrent seizure in a person previously likely to have been an isolated event, or seizure-free and classed Fit for Duty Subject alternatively a diagnosis of epilepsy may be to Review, a consultant review should be made. The worker should be classified obtained. A recurring seizure in a Safety Temporarily Unfit for Duty until the diagnosis Critical Worker will require immediate and response to treatment is determined and suspension from Safety Critical Work. a decision can be made regarding their fitness for duty. Medication Non-compliance: Where non- compliance with medication is suspected, Where seizures occur only at a particular time drug monitoring may be required where of day (for example, in the first hour after appropriate. awakening) a recommendation may be made regarding Fit for Duty Subject to Job Medication Withdrawal: Withdrawal of Modification, limiting working to certain hours medication is usually not compatible with or circumstances. Workers experiencing such continued Safety Critical Work, unless safe or possibly safe seizures must be the explicitly recommended and supervised by a subject of consultant review and their consultant specialised in epilepsy. assessment must includes appropriate Concurrent Conditions: Where epilepsy is documentation of the factors that are associated with other impairments or important to their safety, and the corroboration conditions, the relevant sections covering of eye witnesses whenever possible. those disorders should also be consulted.
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – EPILEPSY
CONDITION CRITERIA Initial or Isolated The criteria for Fit for Duty are not met: Seizures • If the person has had a seizure due to any cause. (an isolated Fit for Duty Subject to Review may be recommended, taking into account the opinion seizure is not of a specialist in epilepsy, and the nature of the work: synonymous with Epilepsy) • If the person has had a single provoked seizure event, and • Provocative factors can be avoided reliably, and • Has been seizure free for one year, and • Takes no anti-epileptic medication, and • The EEG shows no epileptiform activity
Epilepsy The criteria for Fit for Duty are not met: - general • If the person has epilepsy. requirements Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in epilepsy (who may recommend variation of the seizure-free periods in exceptional circumstances), and the nature of the work (avoidance of collapse is particularly important in Category 1 tasks): • If the person has a past history of febrile seizures or of benign childhood epilepsy; and • Does not take anti-epileptic medication; and • The EEG shows no epileptiform activity. or • If the person has a past history of a single seizure event; or of seizures occurring only under provocative circumstances that can be avoided reliably; and • Has been seizure free for five years; and • Takes no anti-epileptic medication; and • The EEG shows no epileptiform activity. (continued overleaf)
Code of Practice for Health Assessment of Rail Safety Workers 49
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – EPILEPSY
CONDITION CRITERIA Epilepsy or - general • If the person has epilepsy and is taking anti-epileptic medication; and requirements • Maintains at least annual review and compliance; and (continued) • Has been seizure free for five years; and • Has had no more than three seizures in the preceding ten years; and • The EEG shows no epileptiform activity. or • If the person has epilepsy and has had surgical treatment; and • Maintains at least annual review; and • Has been seizure free for five years; and • The EEG shows no epileptiform activity. or Taking into account the duties to be performed and the hours to be worked (with conditions including limited and/or restricted duties). • If the person has epilepsy and is taking anti-epileptic medication; and • Maintains periodic review and compliance; and • Has been seizure free for five years; and • The EEG shows no epileptiform activity.
Epilepsy- Recurrent seizure Special situations Recurrence of seizure in a Safety Critical Worker requires immediate suspension from Safety Critical Work. Classify ‘Temporarily unfit for duty’ pending full assessment. Withdrawal of Medication Withdrawal of medication is not compatible with continued Safety Critical Work (unless advised by a consultant).
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
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References 1. Sonnen A. Epilepsy and driving: a European view. 13. Berkovic S.F. Epilepsy Syndromes: Effects on International Bureau for Epilepsy, Haarlem, (1997) Cognition, Performance and Driving ability. Med Law 19:757-761 (2000) 2. Fisher R.S. et al. Epilepsy and driving: an international perspective, Epilepsia 35: 675-684 14. Waller J.A. Chronic medical conditions and traffic (1994) safety. N Engl J Med 273:1413-1420 (1965) 3. Black A. in Bladin P.F. et al. Driving and Epilepsy. 15. Hansotia P & Broste S.K. The effects of epilepsy or ESA, Melbourne (1988) diabetes mellitus on the risk of automobile accidents. N Engl J Med 324:22-26 (1991) 4. Chivell W.C. (Coroner, South Australia) Finding of Inquest 5th October (2001) 16. Taylor J & Chadwick D. Risk of accidents in drivers with epilepsy. J Neurol Neurosurg Psychiat 60:621- 5. Goodridge G.M. & Shorvon S.D. Epileptic seizures in 627 (1996) a population of 6000. Br Med J 287:645-647. 17. Lings S. Increased driving accident frequency in 6. Shorvon S.D. & Reynolds E.H. Early prognosis of Danish patients with epilepsy. Neurology 57:435-439 epilepsy. Br Med J 285:1699-1701 (1983). (2001) 7. Elwes R.D. et al. The prognosis for seizure control in 18. Herner B et al. Sudden illness as a cause of motor newly diagnosed epilepsy. N Engl J Med 311:944-947 vehicle accidents. Br J Ind Med 23:37-41 (1966) (1984) 18. Vander Lugt P.J.M. Traffic accidents and epilepsy. 8. Beghi E. & Tognoni G. Prognosis of epilepsy in newly Epilepsia 16:747-751 (1975) referred patients, Epilepsia 29: 236-243 (1988) 20. Millingen K. Epilepsy and Driving. Proc Aust Assoc of 9. Mattson R.H. et al. A comparison of Valproate with Neurologists 13:67-72 (1976) Carbamazepine. N Engl J Med 327:765-771 (1992) 21 Krumholz A. et al. Driving and Epilepsy. A Review 10. Mattson R.H. et al. Prognosis for total control of and Re-appraisal. JAMA 365:622-626 (1991) complex partial and secondarily generalised tonic clonic seizures. Neurology 47:68-76 (1996) 22. Black A.B. & Lai N.Y. Epilepsy and Driving in South Australia – an assessment of compulsory notification. 11. Cockerell O.C. et al. Prognosis of epilepsy. Epilepsia Med Law 16:253-267 (1997) 38:31-46 (1997) 23. Gastaut H and Zifkin B.G. The risk of automobile 12. Kastelijnij-Nolst Trenite N.G.A. et al. On-line accidents with seizures occurring while driving. detection of transient neuropsychological Neurology 37: 1613-1616 (1987) disturbances during EEG discharges in children with epilepsy. Dev Med Child Neurol 32:46-50 (1990) 24. Chadwick D in Taylor J.F. Medical Aspects of fitness to drive. The Medical Commission on Accident Prevention, London (1995). 25. Somerville, E and ESA Driving Sub-Committee. Consideration of Australian Accident statistics from ABS, FORS and Austroads Websites. Fremantle October 2001.
Further Reading Black A.B. Epilepsy and driving: The Perspective of an Krauss, G.L., et al, Individual state driving restrictions for Australian Neurologist, Med Law 20: 553-568, 2001. people with epilepsy in the US, Neurology, 57, 1780-1782, 2001. Berger J.T. et al. Reporting by physicians of impaired drivers and potentially impaired drivers, J Gen Int Med, 15: 667-672, Lawden, M., Epilepsy surgery, visual fields, and driving, 2000. Journal of Neurology, Neurosurgery and Psychiatry, 68(1), 6, 2000. Chadwick D.W. Driving restrictions and people with epilepsy, Neurology, 57: 1749-1750, 2001. Manji, H., and Plant, G.T., Epilepsy surgery, visual fields, and driving: a study of the visual field criteria for driving in patients after temporal lobe epilepsy surgery with a comparison of Goldmann and Esterman perimetry, Journal of Neurology, Neurosurgery and Psychiatry, 68(1), 80-82, 2000.
Code of Practice for Health Assessment of Rail Safety Workers 51 9. GASTROINTESTINAL AND HEPATIC DISORDERS
9.1 RELEVANCE TO SAFETY were considered unfit to drive and 25% CRITICAL WORK considered questionable. In a second study of real life driving conditions in Chicago the Gastrointestinal and hepatic disorders may results in those patients studied were not affect the ability to perform Safety Critical different from healthy controls. Work due to metabolic disturbances affecting
mental function. However, there is only limited data to support the assumption of a 9.2 MEDICAL CRITERIA FOR SAFETY higher crash rate as a result of gastrointestinal CRITICAL WORKERS and hepatic disorders. Medical criteria for fitness for duty are outlined Hepatic Encephalopathy in the following overleaf. Hepatic encephalopathy describes the As a general rule, gastrointestinal disorders spectrum of potentially reversible neuro- should not interfere with a patient’s ability to psychiatric abnormalities seen in patients with drive/perform Safety Critical Work. Acute liver dysfunction after other neurological conditions require appropriate advice causes or metabolic causes are excluded. regarding working but usually have no impact The vast majority of patients have established on overall fitness for duty although conditions chronic liver disease with signs of chronic liver such as chronic inflammatory bowel disease disease and sometimes those of and stomas will need individual consideration. encephalopathy such as asterixis and the The diagnostic pointers to the presence of fetor hepaticus. chronic liver disease include peripheral signs Working ability will be impaired firstly because such as muscle wasting, spider telangiectasis of the disturbed diurnal sleep pattern and palmar erythema. Signs of hepatic (insomnia and hypersomnia) but further by decompensation will include jaundice, ascites impaired consciousness with levels of oedema as well as the above, while signs of consciousness potentially fluctuating. hepatic encephalopathy will include altered Impairment may also result from focal mentation, fetor hepaticus and asterixis. neurological signs which occasionally develop Not to be ignored are the potentially subtle in such patients. disturbances of mentation that can occur in Treatment of hepatic encephalopathy is the the absence of overt liver failure. An treatment of the underlying liver disease and indication that hepatic encephalopathy is reversing of factors that can precipitate developing might include a disturbed sleep encephalopathy. pattern. Patients may also develop fleeting neurological signs such as hemiplegia. There is dispute regarding the cognitive function of patients with chronic liver disease Assessment of workers with chronic liver and portal hypertension without signs of porta disease for fit for duty will require referral to a systemic encephalopathy. Two studies have specialist whose predominant interest is liver addressed driving motor vehicles in this group disease. of patients and in one study 60% of patients
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MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – GASTROINTESTINAL DISORDERS
CONDITION CRITERIA Hepatic Failure The criteria for Fit for Duty are not met: • If the person has chronic liver disease and clinical evidence of hepatic encephalopathy. If the person has chronic liver disease and no overt evidence of hepatic encephalopathy they may still have impaired cognitive and motor skills and will need to be assessed on an individual basis by their hepatologist. Liver Transplants The criteria for Fit for Duty are not met: • After a liver transplant. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist and the nature of the work: • Noting the reason for the transplant; and • Taking into account the stability of the transplant and the biochemical and haemodynamic response.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Consensus statements on the definition of Hepatic Srivastava, A et al. Fitness to drive in patients with Encephalopathy by the International Working Party at the 11th cirrhosis and portal systemic shunting. A pilot study World Congress of Gastroenterology (Vienna 1998). evaluating driving performance. J Hepatol 1994;21:1023. Quero, JC, et al. The diagnosis of subclinical hepatic Schomerus, H, et al. Latent portasystemic encephalopathy in patients with cirrhosis using encephalopathy. I. Nature of cerebral neuropsychological tests and automated electroencephalogram analysis. Hepatology 1996; 24:556. Cadranel, JF et al, Focal neurological signs in hepatic encephalopathy in cirrhotic patients; An underestimated entity? Am J Gastroenterol 2001; 96:515.
Code of Practice for Health Assessment of Rail Safety Workers 53 10. HEARING
10.1 RELEVANCE TO SAFETY Radio Communication. Radio CRITICAL WORK communication is commonly used about rail yards eg shunters, and along the track eg Substantial hearing loss may affect the ability flagman. Train signallers and controllers need to perform Safety Critical Work due to the to communicate via radio or mobile phone in a inability to communicate or failure to hear quiet background. With the exception of sounds indicating a hazard. drivers, the ability to speak and hear radio communication is a matter for simple There are two main groups of standards, one assessment at placement (and thereafter) by for drivers and one for other rail safety management and no medical standard is set. workers. Both standards have similar screening thresholds based on speech Tram Drivers. For tram drivers, the main frequencies but the subsequent management safety requirement is to hear other traffic on differs. the road. While driving ability per se might not be affected by a hearing deficiency, Train Drivers. Train drivers work in cabs with responsiveness to critical events is an background noise that varies but may reach important safety consideration for drivers. up to 85dB. Drivers need to hear radio These workers therefore require a reasonable communication from central control as well as level of hearing in order to ensure their alarm systems and track detonators. Binaural awareness of changes in engine or other hearing is helpful in distinguishing speech in a noises which may signal developing problems noisy environment. Most radios in engine or hearing emergency vehicles or other cabs can be amplified to help hearing against warning horns, bells, sirens. the background noise. Hearing Aids and Cochlear Implants. Because of the variation in cab noise the Hearing aids, particularly modern (digital) standards are not necessarily applicable ones present particular problems in the rail across all driving tasks. Individual risk industry. Modern aids have the ability to assessments are required in conjunction with recognise speech patterns and to screen out a specialist in occupational medicine to non-speech noise which helps the user determine the appropriate criteria and understand speech, but diminishes the ability examinations. However if variation is made to hear important ‘noise’ such as a warning from the national medical standard this must alarm or detonators when the user is in a cab, be identified on the medical forms and its or horns of trains when about the track. In relevance to portability emphasised to all addition modern hearing aids may have parties. directional microphones which facilitate Other rail safety workers. Workers such as hearing speech when facing a person and shunters and track maintenance personnel help exclude background ‘noise’. However and many others who work in yards or near forward directional microphones would tracks need to be able to hear a warning adversely affect a driver’s ability to hear sound from a train horn for their own safety. A speech from a speaker positioned behind horn is intended to emit about 88dB at 200m them, or a wearer walking about the tracks in the country and 85db at 100m in towns may not hear a warning horn sounded from (draft national standard). The hearing behind. All hearing aids amplify sound and if standard has been set with a wide margin of this is already loud (as in some cabs or near safety to allow for adverse environmental locomotives) may contribute to noise induced conditions and the worker facing away from hearing loss (NIHL). Workers with a cochlear the train. implant will generally have difficulty with speech recognition in occupational Note: workers who are at any time working background noise. A hearing aid or cochlear directly on the track should be regarded as implant may suddenly malfunction. functionally deaf and blind. A hearing standard for their safety is not appropriate and For these reasons, hearing aids or cochlear they require suitable track protection. Also this implants generally should not be used in rail hearing standard and testing should not be safety work Exemptions may be made by an confused with the requirements for ENT surgeon based on careful consideration audiometric monitoring required by OHS of the job requirements in relation to the type regulations for noise-exposed workers. of hearing aid or cochlear implant and a practical test.
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10.2 MEDICAL CRITERIA FOR SAFETY • A control subject should be selected. CRITICAL WORKERS Their hearing should be confirmed to be normal on a recent audiogram to be a Drivers. Medical criteria for fitness for duty valid control. (Some drivers lose hearing are outlined in the table overleaf. Compliance due to noise induced hearing loss or with the standard should be initially assessed other causes and are not valid controls). by audiometry and if the standard is not met a • The subject and control ride in the cab of practical test may be arranged. a train which then simulates a range of Practical tests of hearing may be considered typical driving conditions such as working for drivers who fail the ordinary medical under load, dynamic braking, etc. examinations. However the test is not • The test involves a series (~20 ) of typical intended to imply any relaxation of the track instructions and a few emergency standard for hearing. Different railway instructions being communicated over the systems may differ with respect to the hearing radio system, intended to simulate typical requirements because of the nature of conditions. equipment and tasks. Therefore, it is not • The subject must obtain a score similar to sensible or safe to apply a uniform practical the control to pass. test nationally. The following points outline the principles of conducting a test within a • If the subject passes they may be particular railway. The results of such a test permitted to drive on trains that have are not necessarily valid for any other railway. similar cab noise levels and that utilize a They should be conducted by persons radio-communication system similar to knowledgeable of the work. that on which they were tested. They require a further practical test to be Principles of Practical Hearing Tests permitted to drive on systems with • The noise in the cab of a train may range substantially different noise levels and up to 85dB. It is essential that the driver communication systems. be able to detect and hear radio- • Subjects should be classed as Fit for Duty communications, warning alerts from Subject to Review and their audiogram equipment such as vigilance controls, and reviewed periodically. If there is track detonators against this background appreciable deterioration the practical test noise. Hearing aids may be used in the should be repeated. test (but see above). Other workers. Workers such as shunters • The test should be based on the ability of and others who are around the track require the subject to hear typical “train orders” hearing for their own safety and should meet likely to be transmitted on the radio- the standards as set out for ATTP (Part 2B). communication system. This test will need to be developed in conjunction with experienced engineers and drivers and hearing experts.
Code of Practice for Health Assessment of Rail Safety Workers 55 MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – HEARING
CONDITION CRITERIA Hearing – Train Compliance with the standard should be initially assessed by audiometry without Drivers hearing aids or use of a cochlear implant. The criteria for Fit for Duty are not met: • If the person has an unaided average hearing threshold level of equal to or greater than 40dB in the worse ear. (Average hearing threshold is the simple average of pure tone air conduction thresholds at 500, 1000, 2000 Hz). Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ENT specialist and the nature of the work: • If the person has an unaided average hearing threshold level of less than 40dB in the better ear, and an unaided average hearing threshold of equal to or greater than 40dB in the worse ear. The ENT Specialist is to have regard to: 1. The hearing levels in each ear, and 2. The nature of the relevant background occupational noise, and 3. The nature of the duties of Safety Critical Workers including efficient and reliable use of communication devices including mobile phones, radio- communications, and need to reliably detect emergency alarms in the relevant background occupational noise. • If a practical test is passed (refer text for details). • Please refer to text regarding use of hearing aids. • Cochlear Implantees should be assessed on an individual basis by an ENT surgeon with consideration of the characteristics of the implant including the risk of sudden device failure, the nature of the relevant background noise, and the nature of the duties of Safety Critical Workers including efficient and reliable use of communication devices including mobile phones, radio-communications, and need to reliably detect emergency alarms in the relevant background noise. A practical test must be passed.
Hearing - Others Refer criteria for Around the Track Personnel, PART 2B.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Hearing Disorders and commercial motor vehicle drivers' compiled Levitt, H. & Voroba, B. (1980). Binaural Hearing. In: by the University of Pittsburgh, March 1993. Binaural Hearing and Amplification: Vol I. Libby, E.R. (Ed). Zenetron Inc. Chicago. P. 59-80. Edwards FC, McCallum RI, Taylor PJ 'Fitness for work: The Medical Aspects' Joint Report of the Royal College of Physicians Zurek, P. (1993). Binaural advantages and directional and the Faculty of Occupational Medicine, Oxford University Press, effects in speech intelligibility. In: Acoustical Factors 1988 Affecting Hearing Aid Performance. Studebaker, G.A., Hochberg, I. (Eds.) p.255-276. Second edition. Allen and Expert opinion Bacon.
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11. HIV/AIDS
11.1 RELEVANCE TO SAFETY risks when performing Safety Critical Work are CRITICAL WORK greatly reduced. If the disease progresses to AIDS then various HIV/AIDS may affect the ability to perform organs relevant to working may be affected, Safety Critical Work due to impairment of such as the eyes. mental function or other affects on the body. The human immunodeficiency virus (HIV) is highly neurotropic and may cause 11.2 MEDICAL CRITERIA FOR SAFETY neurological effects which impact on Safety Critical Work ability. However the advent in CRITICAL WORKERS recent years of highly active antiretroviral Safety Critical Workers who are HIV positive therapy (HAART) for patients has had a or have AIDS and are under treatment may be significant impact on their prognosis and their recommended for Fit for Duty Subject to well-being. As a result, there has been a Review, providing they meet the criteria set substantial reduction in neurological sequelae out in this Code for end organ damage which particularly AIDS dementia and progressive may arise as a complication of the disease, for multifocal leukoencephalopathy (PML) so the example, vision.
References Dore, G.J., et al., Changes to AIDS dementia complex in the era of highly active antiretroviral therapy, AIDS, 13, 1249 1253, 1999. Gendelman, H.E., et al., Suppression of inflammatory neurotoxins by highly active antiretroviral therapy in human immunodeficiency virus-associated dementia, Journal of Infectious Disease, 178, 1000-1007, 1998. Li, T.S., et al., Long lasting recovery in CD4 T cell function and viral loading reduction after highly active antiretroviral therapy in advanced HIV-1 disease, Lancet, 351, 1682-1686, 1998. Montaner, J.S.G., Hogg, R.S., and O’Shaughnessy, M.V., Emerging international consensus for use of antiretroviral therapy, Lancet, 341, 1042, 1997.
Code of Practice for Health Assessment of Rail Safety Workers 57
12. METABOLIC AND ENDOCRINE DISORDERS (Excluding Diabetes)
12.1 RELEVANCE TO SAFETY 12.2 MEDICAL CRITERIA FOR SAFETY CRITICAL WORK CRITICAL WORKERS Metabolic and endocrine disorders may affect There are no specific criteria regarding fit for the ability to perform Safety Critical Work due duty for metabolic and endocrine diseases. to effect on mental function or other organs of Because of the diverse manifestation of these the body. Metabolic or endocrine disorders conditions, each person will require individual (Addison’s Disease, Adrenal or Cushing’s assessment. Disease, Hyperthyroidism, Hypothyroidism, Parathyroid Disease, Phaeochromocytoma, If there is a real risk of acute loss of control Pituitary Disorders, Insulinoma) can cause then the criteria would not be met; a many symptoms ranging from generalised recommendation may be made for Fit for Duty asthenia, localised muscle weakness, spasm Subject to Review dependent on stability of to tetany, sudden episodes of dizziness or control of the condition and an appropriate unconsciousness. specialists opinion obtained. Unless controlled by adequate treatment, Specific defects which may be associated with workers so afflicted may pose an increased an endocrine disorder may also need safety risk. evaluation, for example, effects on visual field from pituitary tumours or exophthalmos in hyperthyroidism.
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13. MUSCULOSKELETAL DISORDERS
of a job and with advice from an occupational 13.1 RELEVANCE TO SAFETY physician. CRITICAL WORK The aim of a health assessment is to detect Substantial musculoskeletal disorders may those Safety Critical Workers who may have affect the ability to perform Safety Critical difficulty in performing their duties, and to Work due to inability to adequately control identify those workers who would benefit from machinery and perform bodily movements as job modification. However, modification to required. Most Safety Critical Workers require cabs and other equipment is usually difficult soundness of limbs, neck, back and good because drivers need to rotate between balance although the specific requirements locomotives. vary depending on the task. For example, In many cases a functional assessment of a typically: driver by a Principal Driver (in conjunction with • Driving requires good musculoskeletal an Occupational Therapist if necessary) may capacities to: be helpful. - sit and drive the train using arms and The driver should wear any prosthesis legs; prescribed during an assessment by a - walk about the train on uneven track; Principal Driver. - join heavy couplings, bend and Disability of Cervical Region: Good head check bogies; movement is important to support good fields - enter and exit the cab to/from the of vision. Workers with severe neck pain and ground in emergency. very reduced mobility including that arising • Flagman duties require good from wearing soft collars or braces should be musculoskeletal capacity to: classified as Temporarily Unfit for Duty and - move quickly over uneven track should not perform Safety Critical Work for the duration of their treatment. Some loss of neck - place detonators quickly and movement is allowable if the cab is fitted with accurately on the track adequate outside mirrors. In the case of - signal to trains. permanent disability, the criteria may not be • Shunting requires good musculoskeletal met. capacity to: Disability of Thoracolumbar Region: - move over uneven track Workers with severe pain and reduced - rapidly board/alight trucks or mobility of the thoracolumbar region, including carriages those required to wear a brace or body cast that severely limits mobility, should be open or close stiff, large coupling - classified as Temporarily Unfit for Duty and mechanisms should not perform Safety Critical Work for the - switch points. duration of their treatment. In the case of The musculoskeletal requirements of a job permanent disability, the criteria may not be should be provided to the authorised health met. professional as part of the request for Arthritis: Painful joints may arise due to examination. inflammatory or degenerative arthritis. Workers who have persistent pain and marked 13.2 MEDICAL CRITERIA FOR SAFETY reduction in range of movement in shoulders, CRITICAL WORKERS elbows, wrists, hands, hips, knees, ankles or feet may not meet the criteria. A driver may Medical criteria for fitness for duty for Safety be assessed by a Principal Driver. Critical Workers are outlined in the table overleaf. Post Surgery Including Joint Replacement: It is not possible to detail all the tasks of Workers should generally not perform Safety Safety Critical Workers and the Critical Work for six weeks post major musculoskeletal criteria to be met in this orthopaedic surgery. A Principal Driver’s Standard. Desirably the authorised health opinion may be obtained where appropriate if professional should be acquainted first hand there is ongoing limitation of function. with the job or at least be provided with the Balance: Agility of movement requires good task analysis so as to conduct the examination balance which is assessed using the Romberg with insight when matching demands and Test. (Also refer Vestibular Disorders musculoskeletal capacities. chapter). An organisation may develop its own standards appropriate to the risk assessment
Code of Practice for Health Assessment of Rail Safety Workers 59
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – MUSCULOSKELETAL DISORDERS
CONDITION CRITERIA Musculoskeletal The musculoskeletal activities which are needed for Safety Critical Work as Disorders identified in the task analysis for the workers job should be carefully considered. The criteria of Fit for Duty are not met: • If the ability to perform the activities needed for Safety Critical Work is inadequate. Fit for Duty Subject to Review or Subject to Job Modification may be recommended, taking into account the opinion of a specialist or therapist and/or Principal Driver, and the nature of the work. A practical assessment may be helpful.
ATTP Musculoskeletal criteria for Around the Track Personnel are included in PART 2B requirements of this Volume.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
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14. NEUROLOGICAL DISORDERS (Excluding Epilepsy and Syncope)
14.1 RELEVANCE TO SAFETY Intellectual Impairment: Persons with CRITICAL WORK intellectual impairment are not suitable for Safety Critical Work. Persons with minor Neurological disorders may affect the ability to degrees of impairment should be identified by perform Safety Critical Work due to the affect selection (neuropsychological) tests at time of on mental function or the loss of control of recruitment. Usually this is not a medical or other parts of the body. health assessment matter. At present only limited evidence can be cited Neuro-development Disorders: Specialist about the incidence of accidents across a advice should be sought regarding Safety given population of Safety Critical Workers Critical Workers who have complex conditions such as drivers suffering from a neurological such as ADHD or Tourette’s Syndrome. disorder. However, it is very likely that symptoms which are common to many Stroke: In the event of a stroke the worker neurological conditions, such as potential should not perform Safety Critical Work for a spontaneous loss of consciousness, minimum of one month post event (3 months confusional states, impairment of muscular for subarachnoid haemorrhage) if there is power and coordination are deleterious to significant neurological, perceptual or Safety Critical Work. Sudden incapacity, cognitive deficit. Return to Safety Critical such as from a transient ischaemic attack Work depends upon physician assessment is particularly relevant to Category 1 High and where appropriate, evaluation by a Level Safety Critical Workers. Principal Driver. A visual field defect will usually exclude a person from Safety Critical
Work as will all but minor residual defects in 14.2 MEDICAL CRITERIA FOR SAFETY accordance with these standards. CRITICAL WORKERS Transient Ischaemic Attacks: TIA may Medical criteria for fit for duty are outlined in recur or be harbingers of a full stroke. Safety the table overleaf. Critical Workers who have had only one transient ischaemic episode should be The worker with a neurological disorder must referred to an appropriate specialist to be assessed to determine whether the sum of determine their fitness for duty. If an symptoms and signs, being physical, mental underlying cardiac pathology for such and behavioural is compatible with Safety episodes is identified any recommendation for Critical Work. Fit for Duty Subject to Review, would be Any impairment of consciousness or based upon the prognosis of that condition, awareness, or the presence of confusion or and the likelihood of continued recurrence. loss of visual fields or vertigo, is usually Multiple Sclerosis: Multiple Sclerosis may incompatible with Safety Critical Work. progress to cause poor coordination, Muscular power and coordination should be weakness, vertigo, memory loss, significant adequate to undertake work safely. cognitive impairment, or visual impairment, If the health professional is concerned about a any of which may impair capacity to work worker’s ability to work safely, the opinion of a safely. Where appropriate assessment by a Principal Driver or neuropsychologist may be Principal Driver (and possibly an Occupational helpful. Therapist) may be helpful. Dementia and Other Cognitive Peripheral Neuropathy: Peripheral Impairments: The person should not perform neuropathy may impair working due to Safety Critical Work if there is significant difficulties with sensation (particularly impairment of memory, visuospatial skills, proprioception) or severe weakness insight or judgement or if problematic developing. Where appropriate assessment hallucinations or delusions. Baseline and by a Principal Driver (and possibly an periodic review are required as most forms of Occupational Therapist) may be helpful. cognitive impairment and dementia are Limb Control: A loss of control of a limb due progressive. If unsure in the case of a driver, to paralysis, paresis or other neurological refer to a Principal Driver for further conditions needs to have the severity assessment. Referral to a neuropsychologist assessed on an individual basis. Where may be helpful in cases of cognitive appropriate assessment by a Principal Driver impairment. may be helpful.
Code of Practice for Health Assessment of Rail Safety Workers 61 Intracranial Surgery: In the event of duty. This may include neuropsychological intracranial surgery the worker should not testing and assessment where appropriate by perform Safety Critical Work until cleared by a a Principal Driver as well as referral to a relevant specialist (neurosurgeon/neurologist). neurologist. (See also Epilepsy – surgery). Migraine and Recurrent Headache: Attacks Head Injury: A person who recovers from a of migraine and recurrent headache are loss of consciousness of less than 24 hours common and may impair a person’s ability to with no complications does not present any concentrate and to work safely. Workers who special risk. Similarly, immediate seizures suffer migraine and recurrent headaches which occur within 24 hours of a head injury should have their symptoms and treatment are not considered to be epilepsy, but part of reviewed. A plan of management if an attack the acute process. occurs at work should be discussed and agreed with their supervisor as necessary. Workers who have had minor head injuries Provoking factors such as shift work, lighting should not perform Safety Critical Work and noise may need attention. In severe immediately afterwards. The occurrence of cases Fit for Duty Subject to Review may be persisting functional disturbances requires recommended. careful assessment to determine fitness for
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – NEUROLOGICAL DISORDERS
CONDITION CRITERIA Berry Aneurysms The criteria for Fit for Duty are not met: and other • If the person has a berry aneurysm or other vascular malformation. vascular Fit for Duty Subject to Review may be recommended, taking into account the malformations of opinion of an appropriate specialist and the nature of the work: the brain • After consideration of the risk and the benefits of any treatments.
Cerebral Palsy The criteria for Fit for Duty are not met: (See also • If the capacity to control a vehicle is impaired due to musculoskeletal or Neuromuscular cognitive or neurological causes. and/or Cognitive Fit for Duty Subject to Review may be recommended, taking into account the Disorders) opinion of an appropriate specialist and the nature of the work, and: • The severity of the disabilities; • The interaction between multiple disabilities; • The response to treatments; and • Suitable vehicle modifications. An assessment where appropriate by a Principal Driver may be helpful.
Dementia and The criteria for Fit for Duty are not met: other cognitive • If the person’s dementia or cognitive impairment is confirmed. impairments Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work, and: • The cause of the condition and likely response to treatment; and • Any appropriate neuropsychological tests; and • The result of an assessment by a Principal Driver or equivalent depending on the job.
Head injury The criteria for Fit for Duty are not met: • If the person has had head injury causing chronic functional disturbances. (Acquired brain injury) Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work, and: • The result of neuropsychological testing; and • The result of an assessment by a Principal Driver or equivalent depending on the job (see also Cognitive Impairment); and • Other disabilities that may impair Safety Critical Work per this Code.
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MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – NEUROLOGICAL DISORDERS
CONDITION CRITERIA Migraine See text.
Neglects (While The criteria for Fit for Duty are not met: patient perceives, • If there are neglects present. does not respond appropriately)
Neuromuscular The criteria for Fit for Duty are not met: conditions (MS, • If the person has Parkinsonism, multiple sclerosis, degenerative peripheral Parkinson’s neuropathy, progressive muscular dystrophy or any other severe Disease, Peripheral neuromuscular disorder. Neuropathy) Fit for Duty Subject to Review may be recommended, if the disability is limited to minor effects on Safety Critical Work, taking into account the opinion of a neurologist or rehabilitation specialist and the nature of the work, and: • The response to treatments; and • The result of an assessment by a Principal Driver or equivalent depending on the job; and • Modifications to the job, where practical.
Stroke The criteria for Fit for Duty are not met: • If the person has had a stroke. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work: • If the stroke was caused by a condition that has now been satisfactorily treated. A satisfactory recovery from the stroke, including perceptual deficits, must also be demonstrated. Cases of berry aneurysm should be referred to an appropriate specialist.
Transient The criteria for Fit for Duty are not met: Ischaemic Attacks • If the person has had two or more transient ischaemic attacks. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work (avoidance of sudden incapacity is particularly important in Category 1 tasks): • If the aetiology of the attacks has been identified, the underlying cause removed, and the person has had a six-month period free of attacks.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Code of Practice for Health Assessment of Rail Safety Workers 63 Further reading Bonn, D., Patients with mild Alzheimer’s disease should not Hawley, C.A., Return to driving after head injury, drive, The Lancet, 356, 49, 2000 Journal of Neurology, Neurosurgery and Psychiatry, 70(6), 761-766, 2001. Cox, D.J., et al, Evaluating driving performance of outpatients with Alzheimer’s disease, The Journal of the American Board of Heikkila, V.M., et al, Decreased driving ability in people Family Practice, 11(4), 264-271, 1998. with Parkinson’s disease, Journal of Neurology, Neurosurgery and Psychiatry, 64(3), 325-330, 1998. Drachman, D.A., and Swearer, J.M., Driving and Alzheimer’s disease: the risk of crashes, Neurology, 43(12), 2448-2456, Lachenmayer, L., Parkinson’s disease and the ability to 1993. drive, Journal of Neurology, 247(Suppl 4), 28-30, 2000. Foley, D.J., et al, Driving cessation in older men with incident Lipski, P.S., Driving and dementia: a cause for dementia, Journal of the American Geriatrics Society, 48(8), concern, Medical Journal of Australia, 167(8), 453-454, 928-930, 2000. 1997. Fox, G.K., and Bashford, G.M., Driving and dementia: balancing Schultheis, M.T., Garay, E., DeLuca, J., The influence personal independence and public safety, Medical Journal of of cognitive impairment on driving performance in Australia, 167(8), 406-407, 1997. multiple sclerosis, Neurology, 56(8), 1089-1094, 2001.
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15. PREGNANCY
15.1 RELEVANCE TO SAFETY 15.2 MEDICAL CRITERIA FOR SAFETY CRITICAL WORK CRITICAL WORKERS In normal circumstances, pregnancy should There are no specific criteria regarding fitness not be considered a barrier to Safety Critical for duty for pregnancy. Each person will Work. However, conditions that may be require individual assessment based on the associated with some pregnancies should be considerations above. considered regarding their effect on Safety Critical Work. These include: Gestational Diabetes: If the diabetes occurs only in pregnancy, it should not impact on • fainting or light-headedness; fitness for duty. • hyperemesis gravidarum; Post natal Depression: A Safety Critical • hypertension in pregnancy; and Worker with post natal depression will require • post caesarean section. individual assessment regarding the severity of the condition in relationship to the job. A caution regarding performing Safety Critical (Refer also to Psychiatric Disorders) Work may be required depending on the severity of the symptoms and the expected effects of medication.
Code of Practice for Health Assessment of Rail Safety Workers 65 16. PSYCHIATRIC DISORDERS See also Neurological Disorders, Alcohol and Drugs - Illicit.
16.1 RELEVANCE TO SAFETY immediately classed Temporarily Unfit for CRITICAL WORK Duty pending further assessment. A decision as to whether or not a Safety Critical Worker, Psychiatric disorders may affect the ability to particularly a high level one, should be placed perform Safety Critical Work due to effects on on alternative duties while being further mental function. Safety Critical Work is a assessed will need to be made on a case-by- complicated psychomotor performance which case basis. depends on fine coordination between the The K 10 is used by kind permission of sensory and motor systems. It is influenced Professor Gavin Andrews of the Clinical by factors such as arousal, perception, Research Unit for Anxiety and Depression of learning, memory, attention, concentration, the University of New South Wales. Further emotion, reflex speed, time estimation, information about the K 10 is available at auditory and visual functions, decision-making www.crufad.unsw.edu.au and personality. Complex feedback systems interact to produce the appropriate Other psychiatric conditions coordinated behavioural response. Anything Persons with any substantial mental illnesses that interferes with any of these factors to a (whether acute or chronic) should not perform significant degree may impair Safety Critical Safety Critical Work, although Work ability. For example, inattentiveness due recommendation of Fit for Duty Subject to to a mixture of anxiety arising from a chronic Review may be considered in some domestic situation and some medications may circumstances on the recommendation of a contribute to accidents, or train drivers may be treating psychiatrist. adversely affected by recurrent track suicides. Substantial anxiety – depression affects up to An acute episode of mental illness (for 10% of the adult population. This has lead to example, psychosis, acute mania or panic introduction of the K10 screening tool to attack) poses a substantial risk. Such an detect severe cases of this common condition. episode in a Safety Critical Worker would mean the criteria for fitness for duty are not met and the person should be classed 16.2 MEDICAL CRITERIA FOR SAFETY Temporarily Unfit for Duty pending CRITICAL WORKERS assessment. Medical criteria for fitness for duty are outlined Some medications for mental illness may in the table overleaf. affect Safety Critical Worker alertness and coordination. However, the use of more Screening for anxiety/depression – Use of modern drugs with less side-effects the K10 Questionnaire (especially antipsychotics) may improve The K 10 questionnaire should be applied as compliance and therefore reduce symptoms. follows: There may need to be a trial period of the medication when the person should be 1. Each question is scored as follows: classed Temporarily Unfit for Duty. All of the time 5 Dementia and Other Cognitive Impairments Most of the time 4 The person should not perform Safety Critical Work if there is significant impairment of Some of the time 3 memory, visuospatial skills, insight or A little of the time 2 judgement or if problematic hallucinations or delusions. Baseline measures and periodic None of the time 1 review are required as most forms of cognitive 2. The values are then summed. If the total is impairment and dementia are progressive. If nineteen (19) or greater (or other clinical unsure in the case of a driver, refer to a observations warrant it) discuss the findings Principal Driver for further assessment. with the patient. Determine possible Referral to a neuropsychologist may be helpful explanations such as work stress or domestic in cases of cognitive impairment. crises or endogenous causes and agree an Personality Disorder approach to management of the condition eg Persons with personality disorders often show referral to GP/psychiatrist or to Employee disregard for social values and rules. They Assistance Program, marital or financial are unsuitable for Safety Critical Work. counsellor, etc. Persons with unsuitable personality 3. Persons with raised K10 scores (19 or traits/attitudes should be identified by greater) do not meet the criteria of Fit for Duty. selection (neuropsychological) tests at time of In most cases the patient will need to be
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recruitment. Usually this is not a medical or Where a mental health condition is associated health assessment matter. with epilepsy or illicit drug use, the relevant section should also be referred to. Neuro-development Disorders Specialist advice should be sought regarding BRUCE – more information needed to guide Safety Critical Workers who have complex Temp Unfit for above. conditions such as ADHD or Tourette’s Syndrome.
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – PSYCHIATRIC DISORDERS
CONDITION CRITERIA K10 Score The criteria for Fit for Duty are not met: • If the person has a K10 score of 19 or greater The person in most cases will be classified Temporarily Unfit for Duty pending review while the causes are being assessed and managed.
Psychiatric The criteria for Fit for Duty are not met: disorders • If the person has an acute or chronic psychosis, whether schizophrenic, bipolar (manic or depressive phase) or other depressive psychosis; or • If the person has a personality or psychiatric disorder with features such as aggression or violence which are hazardous to Safety Critical Work; or • If the person is taking psychoactive drugs which will impair Safety Critical Work performance on a long term basis; or • If the person’s judgement or perceptual, cognitive or motor function is affected by mental disorder (for example, ADHD); or • If the examining doctor believes that there is a significant risk of previous psychotic condition relapsing. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a psychiatrist, and the nature of the work: • If the condition is well controlled and the person is compliant with treatment over a substantial period; and • The person is taking medication that minimises the risk of cognitive or other side effects that might affect Safety Critical Work. • Any appropriate neuropsychological tests; and • The result of an assessment by a Principal Driver, or equivalent depending on the job, may be helpful.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms that could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further reading Hollister, L.E., Automobile driving by psychiatric patients, American Wylie, K.R., Thompson, D.J., Wildgust, H.J., Effects of Journal of Psychiatry, 149(2), 274, 1992. depot neuroleptics on driving performance in chronic schizophrenic patients, Journal of Neurology, Neurosurgery, and Psychiatry, 56(8), 910-913, 1993.
Code of Practice for Health Assessment of Rail Safety Workers 67 17. RENAL FAILURE
17.1 RELEVANCE TO SAFETY impairments seen in dialysis treated end stage CRITICAL WORK renal failure patients. Successful kidney transplantation reverses Renal failure may affect the ability to perform most of the metabolic or functional impairment Safety Critical Work due to metabolic of chronic renal failure, including those likely disturbances affecting mental function. to be relevant to the task, and (after the initial Chronic Renal Failure: Potential impact from post operative recovery) persons with kidney chronic renal failure on the performance of transplants who have good renal function are Safety Critical Work can result from: not regarded as impaired from a Fit for Duty • The metabolic consequences of uraemia point of view. itself; The risks associated with the The initiation of dialysis treatment is associated secondary complications of chronic renal with some metabolic and cardiovascular disease and its treatment, in particular adjustment and may be associated with cardiovascular problems, labile increased functional impairment. It is hypertension, post dialysis hypotension, considered prudent to avoid performing Safety cramp, volume overload, congestive Critical Work for the first few treatments or cardiac failure, and accelerated weeks of treatment, but after this individually atherosclerosis; or variable period, most patients achieve a • The underlying cause of the chronic renal reasonable symptomatic or functional state, failure (eg: 25% of dialysis patients have which is maintained by ongoing dialysis diabetes mellitus, a disease with its own treatment. risks of impairing Safety Critical Work The combination of the subtle cognitive including retinopathy which is commonly impairment, probably present in most patients associated with diabetic nephropathy). with advanced chronic renal failure, together There are described abnormalities in with co-morbidities associated with renal psychophysical ability in stable dialysis failure and dialysis, suggests a conservative, patients which may be relevant to working or restrictive approach in the high-risk safely. Dialysis treatment has improved situation of Safety Critical Work. significantly in the twenty years since the only Proteinuria is a reliable marker for chronic relevant literature was published, and renal disease. In an elderly population, the erythropoietin therapy has resulted in the cause of proteinuric renal disease (eg: disappearance of anaemia. There is no diabetes or ischaemic vascular disease) may detailed recent literature on the functional be the more relevant factor in impairment. ability of chronic renal failure/dialysis patients in relation to working safely, and no firm Acute Renal Conditions and Recurrent evidence based recommendations can be Acute Conditions: Glomerular disease in the made. absence of severe renal failure or hypertension, and recurrent urinary tract
infection do not have any associated risk. 17.2 MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS Renal Calculus Disease, with Renal Colic: is a condition that can cause acute severe Medical criteria for Fit for Duty are outlined in pain, which could, in some instances severely the table overleaf. impair Safety Critical Work. After a first stone episode, the risk of recurrence is only 14% at The renal condition most commonly relevant one year and 35% at five years. Most to a fitness for duty assessment is chronic episodes of colic will commence with some renal failure. Chronic renal failure may be milder prodromal symptoms, sufficient to allow 'end stage' requiring treatment by dialysis or a train driver to stop or a flagman to radio for kidney transplantation, or less severe renal help, and there are no published data failure, which has not yet progressed to end supporting a risk for Safety Critical Work such stage. as driving from calculus disease. The risk While mild chronic renal failure is not usually from recurrent calculi is, therefore, considered associated with significant symptomatic or to be remote and differs from the situation with functional impairment, late stage chronic renal aeroplane pilots, for whom the option of failure (Glomerular Filtration Rate (GFR) immediately landing is not available. approximately <20% of normal), although not 'end-stage', may have some of the clinical
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MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – RENAL FAILURE
CONDITION CRITERIA Renal The criteria for Fit for Duty are not met: Failure • If the person has end-stage renal failure (requiring dialysis) or advanced predialysis renal failure (GFR <20% of normal). Fit for Duty Subject to Review may be recommended, taking into account the opinion of a renal specialist and the nature of the work: • If the patient’s condition is stable with limited co-morbidities per this Code.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms that could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Schewe G, Eisenhauer T, Leber H, Lindner U, Ludwig O, Stewart RB, Moore MT, Marks RG, May FE, Hale WE. Shcuster R [Studies on psychophysical ability of kidney transplant Driving accidents in the elderly: an analysis of receivers with regard to the question of driving aptitude] [German] symptoms, diseases and medications. J. Geriatric Drug Bietrage zur Gerichtlichen Medizin. 1982;40:265-273. Therapy. 1993:8:31-44. Schewe G, Broens R, Dietz B, Lange H, Ludwig O, Schuster R Lyman JM, McGwin G, Sims RV. Factors related to [Studies on psychophysical ability of dialysis patients with regard driving difficulty and habits in older drivers. Accident to the question of driving aptitude] [German] Bietrage zur Analysis and Prevention, 2001:31:413-421 Gerichtlichen Medizin. 1982;40:249-264. Uribarri J, Oh MS, Carroll HJ. The first kidney stone. Fraser CL, Arieff AI. Nervous system complications in uraemia. Ann. Int. Med. 1989;111:1006-1009. Ann. Int. Med. 1988;109:143-153.
Code of Practice for Health Assessment of Rail Safety Workers 69 18. RESPIRATORY DISEASES AND SPEECH
18.1 RELEVANCE TO SAFETY following loss of consciousness, unless CRITICAL WORK otherwise cleared by a specialist. Severe respiratory disease is not compatible Respiratory disease and speech disorders with Safety Critical Work. A driver’s duties may affect the ability to perform Safety Critical require not only sitting in a cab, but also ability Work. This is partly because considerable to walk along the train and inspect couplings exertion may be required to work safely and in and in an emergency the ability to exit the cab other circumstances normal blood gases are and deal with unpredictable circumstances. required to enable vigilance to be maintained Flagman must be able to move quickly along and appropriate decisions made. the track. Portable oxygen is impractical in Clear speech is required for communication these jobs. particularly by radio-communication systems Post Thoracotomy: Post thoracotomy regarding normal operating as well as patients generally should not perform Safety emergency situations. Critical Work for four weeks unless cleared by a specialist. Lung transplant patients should 18.2 MEDICAL CRITERIA FOR SAFETY be managed similarly as with heart transplant CRITICAL WORKERS (see Cardiovascular). Medical criteria for Fit for Duty are outlined in Laryngectomy and Tracheostomy: Persons the following table. with a tracheostomy or laryngectomy need to be assessed regarding their ability to speak Severe Chronic Asthma: Careful assessment clearly including use of radio-communications of the ability to perform Safety Critical Work is while still performing Safety Critical Work.. A warranted in severe chronic asthma. Workers practical test may be helpful. should not perform Safety Critical Work for two weeks following admission to an ICU or
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – RESPIRATORY DISEASES
CONDITION CRITERIA Laryngectomy The criteria for Fit for Duty are not met: and • Post Laryngectomy or Tracheostomy. Tracheostomy Fit for Duty Subject to Review may be recommended after practical assessment such as with phones or radio communication devices, etc.
Long – term The criteria for Fit for Duty are not met: Oxygen therapy • If the person has unstable disease requiring oxygen therapy.
Respiratory The criteria for Fit for Duty are not met: Failure • If the person has severe respiratory failure. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a respiratory physician, and the nature of the work: After consideration of the severity of the person’s condition and the likelihood of control of the failure.
Thorocotomy The criteria for Fit for Duty are not met: • Post thorocotomy for at least 4 weeks as determined by the treating surgeon.
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Temporary Illnesses. This Code does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms that could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Worker. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Crockett AJ, Moss JR, Cranston JM, Alpers JH. Domiciliary Hjalmarsen A, Waterloo K, Dahl A, Hjorde R, Viitanen M. oxygen for chronic obstructive pulmonary disease. Cochrane Effect of long-term oxygen therapy on cognitive and Database Syst Rev 2000; CD 001744. neurological dysfunction in chronic obstructive pulmonary disease. Eur Neurol 1999; 42: 27-35.
Code of Practice for Health Assessment of Rail Safety Workers 71
19. SLEEP DISORDERS
19.1 RELEVANCE TO SAFETY Fatigue is a major cause of road accidents CRITICAL WORK and rail by extrapolation. Sleepiness and sleep disorders are one important aspect of Excessive sleepiness during the day, which managing the risks of fatigue1. Fatigue manifests itself as a tendency to doze at programs typically involve attention to rosters inappropriate times when intending to stay and sensible financial rewards, as well as awake, can arise from many causes and is education about the importance of sleep, associated with an increased risk of accidents. sleep hygiene including adequate facilities for sleeping, and advice on diet and alcohol use A number of medical sleep disorders, for and medication1. example, may cause excessive daytime sleepiness, including the sleep apnoea Treatment of obstructive sleep apnoea with syndromes (obstructive sleep apnoea, central nasal continuous positive airways pressure sleep apnoea and nocturnal hypoventilation), (CPAP) has been shown to reduce daytime periodic limb movement disorder, circadian sleepiness and reduce the risk of accidents rhythm disturbances (for example, advanced back to control levels 8, 10, 18, 19. CPAP has or delayed sleep phase syndrome), some also been shown to improve driving simulator forms of insomnia and narcolepsy. Such sleep performance to control levels 20. Mandibular disorders may affect the ability to perform advancement splints have also been used to Safety Critical Work due to sleepiness per se treat obstructive sleep apnoea. While they and/or altered blood gases and hypoxia reduce daytime sleepiness and improve affecting mental function. vigilance, studies have not been performed to assess whether they reduce motor vehicle Information about risk of accidents due to accident rates22- 24. (LOE-III-2) sleep disorders mainly comes from road crash data. Studies have shown an increased rate It is important to distinguish sleepiness (the of motor vehicle accidents two to seven times tendency to fall asleep) from fatigue or that of control subjects in those with tiredness, which is not associated with a sleep apnoea 9--13. Studies have also tendency to fall asleep. Many chronic demonstrated increased objectively measured illnesses cause fatigue without increased sleepiness while driving (electro- sleepiness. encephalography and eye closure Sleep Apnoea measurements) and impaired driving simulator 3, 14, 15 Sleep apnoea is present on overnight performance in sleep apnoea patients . monitoring in 9% of adult women and 24% of This performance impairment is similar to that adult men 4, 5. Sleep apnoea syndrome seen due to illegal alcohol impairment or sleep 16 (excessive sleepiness in combination with deprivation . Drivers with severe sleep sleep apnoea on overnight monitoring) is disordered breathing (respiratory disturbance present in 2% of women and 4% of men. index greater than 34) may have a much Some studies have suggested a higher higher rate of accidents than those with a less 6, 7 26 prevalence in (transport) drivers . (LOE-III- severe sleep disorder . (LOE-III-2) 2) Those with narcolepsy perform worse than Obstructive sleep apnoea involves repetitive control subjects on simulated driving tasks 28, 29 obstruction to the upper airway during sleep, and are more likely to have accidents . precipitated by relaxation of the dilator (LOE-III-2) muscles of the pharynx and tongue, and/or Increased sleepiness during the daytime may narrowing of the upper airway, and resulting in also occur in otherwise normal people and cessation (apnoea) or reduction (hypopnoea) may be due to: of breathing. • prior sleep deprivation (restricting the time Central sleep apnoea refers to a similar for sleep) pattern of cyclic apnoea or hypopnoeas • poor sleep hygiene habits caused by oscillating instability of respiratory neural drive, and not due to upper airways • irregular sleep wake schedules (eg factors. This condition is less common than rosters) obstructive sleep apnoea and is associated • influence of sedative medications with cardiac or neurological conditions or may including alcohol. be idiopathic. Hypoventilation associated with Insufficient sleep (less than five hours) is chronic obstructive pulmonary disease or strongly related to accident risk10. chronic neuromuscular conditions may also interfere with sleep quality causing excessive These factors may increase the severity of sleepiness. sleep disorders and result in more severe sleepiness in workers with sleep disorders26.
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Sleep Apnoea Assessment: Common 19.3 MEDICAL CRITERIA FOR SAFETY indicators of the possibility of sleep apnoea CRITICAL WORKERS include habitual snoring during sleep, witnessed apnoeic events, falling asleep Determining sleepiness is a clinical decision. inappropriately (particularly during non- Subjective measures include tools such as the stimulating activities) and feeling tired despite Epworth Sleepiness Scale1. Which is adequate time in bed8. Poor memory and incorporated into the Safety Critical Worker concentration, morning headaches and health assessment insomnia may also be presenting features. The condition is more common in men and Use of the Epworth Sleepiness Scale with increasing age. (ESS): The ESS is scored by summing the numeric values in the boxes in the Physical features commonly found in those questionnaire; the maximum possible is 8 x 3 with sleep apnoea include obesity, a thick = 24. neck and a narrow oedematous (‘crowded’) oropharynx. Sleep apnoea may be present A score of 0 to 10 is within the normal range. without these features however. Specific Mild to moderate self reported sleepiness questioning in relation to each of the clinical (Epworth Sleepiness Scale score of 11 to 15) disorders, for example, snoring, witnessed may be associated with a significant sleep apnoeas, limb jerking, or cataplexy will focus disorder, although the degree of increased on the likelihood of a specific sleep disorder. risk of sleepiness-related (motor vehicle) Workers in whom sleep apnoea is suspected, accidents is unknown. chronic excessive sleepiness or another Scores of 16 to 24 are consistent with medical sleep disorder should be referred to a moderate to severe sleepiness and are specialist medical sleep physician for further associated with an increased risk of investigation such as overnight sleepiness related motor vehicle accidents polysomnography and appropriate referral to (odds ratio 15.2) 1. (LOE-III-2) an ENT surgeon. If the score is raised (>15) or other clinical Narcolepsy: Narcolepsy is present in 0.05% findings warrant it, discuss the findings with of the population and usually starts in the the patient to determine possible explanations 27 second or third decade of life . Sufferers such as rosters or sleep disorders and agree present with excessive sleepiness and can an approach to management eg referral to have periods of sleep with little or no warning GP, or referral to sleep clinic for of sleep onset. Other symptoms include polysomnography, or a letter to management cataplexy, sleep paralysis and vivid about rosters, etc. In most cases the patient 28, 29. hypnogogic hallucinations The majority will need to be immediately classed of sufferers are HLA-DR2 positive. There is a Temporarily Unfit for Duty pending further sub-group of individuals who are excessively assessment. sleepy, but do not have all the diagnostic features of narcolepsy. Inadequate warning of Objective measures of sleepiness include the oncoming sleep, and cataplexy, put Safety maintenance of wakefulness test (MWT) and Critical Workers at high risk. multiple sleep latency test (MSLT). Excessive sleepiness on the maintenance of Diagnosis of narcolepsy is made on the wakefulness test is related to impaired driving combination of clinical features, HLA typing performance 2. and multiple sleep latency test (MSLT) with a diagnostic sleep study on the prior night to General Recommendations for Sleep exclude other sleep disorders and aid Apnoea, Narcolepsy or Other Sleep interpretation of the MSLT39, 31. Disorder: Any worker with unexplained daytime sleepiness while working or having an Subjects suspected of having narcolepsy off-duty motor vehicle accident potentially should be referred to a respiratory or sleep caused by sleepiness, or an ESS Score of 16 physician or neurologist for assessment to 24 (consistent with moderate to severe (including a multiple sleep latency test) and sleepiness) should be classed Temporarily management. They should have a review at Unfit for Duty pending review and considered least annually by their specialist. for referral to a sleep disorders specialist for Sleepiness in narcolepsy may be managed assessment. effectively with scheduled naps and stimulant medication32-34. Tricyclic antidepressants and MAO inhibitors are used to treat cataplexy35. (LOE-II) 1 The Epworth Sleepiness Scale is under copyright to Dr Murray Johns 1991-1997. It may be used by individual doctors without permission, but use on a commercial basis must be negotiated. It is included in the Safety Critical Worker Health Assessment Questionnaire.
Code of Practice for Health Assessment of Rail Safety Workers 73
All workers suspected of having, or found to • attend review appointments and have, sleep apnoea or other sleep disorders • honestly report their condition to their should be warned about potential impact on treating physician Safety Critical Work. General advice should include: Safety Critical Workers who are diagnosed • minimising unnecessary working at times with obstructive sleep apnoea syndrome and when normally asleep require treatment are advised to have annual review by a sleep specialist to ensure that • allowing adequate time for sleep adequate treatment is maintained. For • avoiding working after having missed a workers who are treated with CPAP it is large portion of their normal sleep recommended that they should use CPAP • avoiding alcohol and sedative machines with a usage meter to allow medications, objective assessment and recording of treatment compliance 35. Appropriate referral • resting if sleepy. to an ENT surgeon should be made. The Safety Critical Worker is responsible to: Assessment of sleepiness should be made and objective measurement of sleepiness • avoid working if they are sleepy should be considered (maintenance of • comply with treatment including wakefulness test and/or or multiple sleep management of lifestyle factors latency test), particularly if there is concern • maintain their treatment device regarding persisting sleepiness or treatment compliance.
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – SLEEP DISORDERS
CONDITION CRITERIA ESS Score The criteria for Fit for Duty are not met: • If the person has a ESS score of 16 or greater The person in most cases will be classified Temporarily Unfit for Duty Pending Review while the causes are being assessed and managed.
Sleep Apnoea The criteria for Fit for Duty are not met: • If the person has established sleep apnoea syndrome (sleep apnoea on a diagnostic sleep study and excessive daytime sleepiness), with moderate to severe sleepiness, until treatment is effective. • If there is a history suggestive of sleep apnoea in association with severe daytime sleepiness, until investigated and treated. Severe sleepiness is indicated by frequent self reported sleepiness while working, motor vehicle crashes caused by inattention or sleepiness or an Epworth Sleepiness Scale Score of 16 to 24 2, 37, 38. (LOE-III-2) Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in sleep disorders, and the nature of the work: • For those with established sleep apnoea syndrome (sleep apnoea on a diagnostic sleep study and excessive daytime sleepiness) who are on satisfactory treatment 10. (LOE-IV) • Consideration should be given to how long-distance drivers will comply with treatment such as CPAP 11, 13. (LOE-III-2)
Narcolepsy The criteria for Fit for Duty are not met: • If narcolepsy is confirmed 27, 28. (LOE-III-3) Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in sleep disorders, and the nature of the work, after the following requirements are met: • A clinical assessment has been made by a sleep physician or neurologist; and • Cataplexy has not been a feature in the past; and • Medication is taken regularly; and • There has been an absence of symptoms for six months; and • Normal sleep latency present on MWT (on or off medication). (Expert Opinion)
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MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – SLEEP DISORDERS
CONDITION CRITERIA Other causes of See guidelines in text excessive daytime sleepiness
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms that could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further reading
Fairclough, S.H., and Graham, R., Impairment of driving Hack, M.A., et al, Comparison of the effects of sleep performance caused by sleep deprivation or alcohol: a deprivation, alcohol and obstructive sleep apnoea (OSA) on comparative study, Human Factors, 41(1), 118-128, 1999. simulated steering performance, Respiratory Medicine, 95(7), 594-601, 2001.
Code of Practice for Health Assessment of Rail Safety Workers 75
References
1. Fatigue Expert Group Options for Regulatory Approach 21. George, C.F., A.C. Boudreau, and A. Smiley, Effects to Fatigue in Drivers of Heavy Vehicles in Australia and of nasal CPAP on simulated driving performance in New Zealand, February 2001, NRTC. patients with obstructive sleep apnoea. Thorax, 1997. 2. Stutts, J.C., J.W. Wilkins, and B.V. Vaughn, Why Do 52(7): p. 648-53. People Have Drowsy Driver Crashes?, . 1999, AAA 22. Bloch, K.E., et al., A randomized, controlled crossover Foundation for Traffic Safety: Washington. p. 1-85. trial of two oral appliances for sleep apnea treatment. 3. Hakkanen, H., et al., Blink duration as an indicator of American Journal of Respiratory & Critical Care driver sleepiness in professional bus drivers. Sleep, Medicine, 2000. 162(1): p. 246-51. 1999. 22(6): p. 798-802. 23. Mehta, A., et al., A randomized, controlled study of a 4. Bearpark, H., et al., Snoring and sleep apnea. A mandibular advancement splint for obstructive sleep population study in Australian men. Am J Respir Crit apnea. American Journal of Respiratory & Critical Care Med, 1995. 151(5): p. 1459-65. Care Medicine, 2001. 163(6): p. 1457-61. 5. Young, T., et al., The occurrence of sleep-disordered 24. Pancer, J., et al., Evaluation of variable mandibular breathing among middle-aged adults [see comments]. advancement appliance for treatment of snoring and N Engl J Med, 1993. 328(17): p. 1230-5. sleep apnea. Chest, 1999. 116(6): p. 1511-8. 6. Stoohs, R.A., et al., Sleep and sleep-disordered 25. Ferguson, E., et al., Road Crash Costs in Australia, . breathing in commercial long-haul truck drivers. Chest, 2000, Bureau of Transport Economics: Canberra. p. 1995. 107(5): p. 1275-82. 102. 7. Howard, M., et al., Seep Disordered Breathing In 26. O'Donnell, C.P., et al., Effect of sleep deprivation on Victorian Transport Drivers. AJRCCM, 2001. 163(5): p. responses to airway obstruction in the sleeping dog. J A933. Appl Physiol, 1994. 77(4): p. 1811-8. 8. Maislin, G., et al., Apnoea risk as determined by a short 27. Hublin, C., et al., Epidemiology of narcolepsy. Sleep, self-administered assessment tool is associated with 1994. 17(8 Suppl): p. S7-12. crash rates in a population of commercial motor vehicle 28. Overeem, S., et al., Narcolepsy: clinical features, new operators. Sleep Research, 1997. 26: p. 421. pathophysiologic insights, and future perspectives. J 9. Horstmann, S., et al., Sleepiness-related accidents in Clin Neurophysiol, 2001. 18(2): p. 78-105. sleep apnea patients. Sleep, 2000. 23(3): p. 383-9. 29. Bassetti, C., Narcolepsy. Curr Treat Options Neurol, 10. Connor, J., et al., The role of driver sleepiness in car 1999. 1(4): p. 291-298. crashes: a systematic review of epidemiological studies. 30. Aldrich, M.S., Diagnostic aspects of narcolepsy. Accident Analysis & Prevention, 2001. 33(1): p. 31-41. Neurology, 1998. 50(2 Suppl 1): p. S2-7. 11. George, C.F., Reduction in motor vehicle collisions 31. Aldrich, M.S., R.D. Chervin, and B.A. Malow, Value of following treatment of sleep apnoea with nasal CPAP. the multiple sleep latency test (MSLT) for the Thorax, 2001. 56(7): p. 508-12. diagnosis of narcolepsy. Sleep, 1997. 20(8): p. 620-9. 12. Teran-Santos, J., A. Jimenez-Gomez, and J. Cordero- 32. Broughton, R.J., et al., Randomized, double-blind, Guevara, The association between sleep apnea and the placebo-controlled crossover trial of modafinil in the risk of traffic accidents. Cooperative Group Burgos- treatment of excessive daytime sleepiness in Santander [see comments]. N Engl J Med, 1999. narcolepsy. Neurology, 1997. 49(2): p. 444-51. 340(11): p. 847-51. 33. Fry, J.M., Treatment modalities for narcolepsy. 13. Young, T., et al., Sleep-disordered breathing and motor Neurology, 1998. 50(2 Suppl 1): p. S43-8. vehicle accidents in a population- based sample of 34. Helmus, T., et al., The alerting effects of short and employed adults. Sleep, 1997. 20(8): p. 608-13. long naps in narcoleptic, sleep deprived, and alert 14. Findley, L.J., et al., Driving simulator performance in individuals. Sleep, 1997. 20(4): p. 251-7. patients with sleep apnea. Am Rev Respir Dis, 1989. 35. Brooks, S.N. and C. Guilleminault, New insights into 140(2): p. 529-30. the pathogenesis and treatment of narcolepsy. Curr 15. Risser, M.R., J.C. Ware, and F.G. Freeman, Driving Opin Pulm Med, 2001. 7(6): p. 407-10. simulation with EEG monitoring in normal and 36. Douglas, N.J. and H.M. Engleman, Effects of CPAP obstructive sleep apnea patients. Sleep, 2000. 23(3): p. on vigilance and related functions in patients with the 393-8. sleep apnea/hypopnea syndrome. Sleep, 2000. 16. Turkington, P.M., et al., Relationship between 23(Suppl 4): p. S147-9. obstructive sleep apnoea, driving simulator 37. Masa, J.F., M. Rubio, and L.J. Findley, Habitually performance, and risk of road traffic accidents. Thorax, sleepy drivers have a high frequency of automobile 2001. 56(10): p. 800-5. crashes associated with respiratory disorders during 17. Maislin, G., et al., A survey screen for prediction of sleep. American Journal of Respiratory & Critical Care apnea. Sleep, 1995. 18(3): p. 158-66. Medicine, 2000. 162(4 Pt 1): p. 1407-12. 18. Gurubhagavatula, I., G. Maislin, and A.I. Pack, An 38. Lloberes, P., et al., Self-reported sleepiness while Algorithm to Stratify Sleep Apnea Risk in a Sleep driving as a risk factor for traffic accidents in patients Disorders Clinic Population. Am J Respir Crit Care Med, with obstructive sleep apnoea syndrome and in non- 2001. 164(10): p. 1904-1909. apnoeic snorers. Respiratory Medicine, 2000. 94(10): 19. Cassel, W., et al., Risk of traffic accidents in patients p. 971-6. with sleep-disordered breathing: reduction with nasal 39. Mitler, M.M., et al., Sleep latency on the maintenance CPAP. Eur Respir J, 1996. 9(12): p. 2606-11. of wakefulness test (MWT) for 530 patients with 20. Krieger, J., et al., Accidents in obstructive sleep apnea narcolepsy while free of psychoactive drugs. patients treated with nasal continuous positive airway Electroencephalography & Clinical Neurophysiology, pressure: a prospective study. The Working Group 1998. 107(1): p. 33-8 ANTADIR, Paris and CRESGE, Lille, France. Association Nationale de Traitement a Domicile des Insuffisants Respiratoires. Chest, 1997. 112(6): p. 1561-6.
76 Department of Infrastructure
20. SYNCOPE / BLACKOUTS
20.1 RELEVANCE TO SAFETY 20.2 MEDICAL CRITERIA FOR SAFETY CRITICAL WORK CRITICAL WORKERS Unpredictable, spontaneous loss of Medical criteria for Fit for Duty are outlined in consciousness is incompatible with Safety the following table. Critical Work. Syncopal/blackout episodes may arise from various causes including: Some of these conditions are temporary (for example, fainting in hot weather) and do not • cardiac (for example, arrhythmias, flow impact on fitness for duty. However, in the obstruction); event of an unexplained episode of • hypotension due to inappropriate syncope/blackouts consideration must be vasodilation (for example, vaso-vagal given to discontinuation of performing Safety faints, autonomic system disorder); Critical Work until the cause is ascertained • neurogenic (for example, epilepsy, and treated. transient ischaemic attacks); Where a firm diagnosis has been made, the • metabolic (for example, hypoglycaemia); standard appropriate to the condition should or be referred to in the Code. For recurrent • psychiatric (for example, hyperventilation, syncope/blackouts which is not covered psychosomatic states). elsewhere in this Volume refer to the table below. Determination of the cause of syncope/blackout may be difficult and require extensive investigations and referral to several specialists.
MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – SYNCOPE/BLACKOUTS
CONDITION CRITERIA Syncope The worker should not perform Safety Critical Work for six months following unexplained syncope/blackouts, although a shorter period may be advised by an appropriate specialist. The criteria for Fit for Duty are not met:
• If the person suffers from unheralded recurrent syncope/blackouts which do not respond to treatment.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Code of Practice for Health Assessment of Rail Safety Workers 77
21. VESTIBULAR DISORDERS
21.1 RELEVANCE TO SAFETY The opinion of an otorhinolaryngologist may CRITICAL WORK be sought. Subsequent to an initial attack of vertigo due Vestibular disorders may affect the ability to to acute labyrinthitis (deafness and vertigo), perform Safety Critical Work due to their affect there may be further recurrence of vertigo for on balance. Safety Critical Work ability is up to twelve months. Given that there are no dependent on the normal functioning of the peremptory symptoms, a sudden inability to vestibular mechanism to sense movement and work safely may eventuate. The person position and may be impaired by defects in should not perform Safety Critical Work while balance. symptoms persist. Vestibular disorders may vary between In cases of acute neurolabyrinthitis (syn. symptomatic and asymptomatic with little vestibular neuronitis, viral infection of the warning. Vestibular malfunction can occur vestibular nerve) which causes nystagmus suddenly and with sufficient severity to make and vertigo, recurrence of symptoms can safe driving or other Safety Critical Work present for many years despite treatment. impossible. It is often accompanied by This makes it quite difficult to isolate a given nystagmus, which compounds the disability. phase of the condition where symptoms In addition, drivers need to be able to enter deleterious to an individual’s fitness for duty and exit the cab to and from the ground in may be present. emergency situations and require balance to do so. All Safety Critical Workers need to In confirmed Meniere’s disease, vestibular walk and in emergency to run, along ballast malfunction and nystagmus can occur despite and other uneven surfaces and require good treatment. The natural history is of balance. progression in the affected ear associated with increasing hearing loss until in the extreme total loss of vestibular function and 21.2 MEDICAL CRITERIA FOR SAFETY partial loss of cochlear function in the affected CRITICAL WORKERS ear. Medical criteria for fitness for duty are outlined Benign paroxysmal positional vertigo in the following table. (BPPV): Generally patients with BPPV will Generally, those who suffer from unheralded not have symptoms in the upright position. attacks of vertigo are Not Fit for Duty. However, workers with BPPV and symptoms in the upright position should not perform Vestibular function should be clinically Safety Critical Work such as climbing ladders assessed by using a simple Romberg Test, while symptoms persist and should be free of which is also required for neurological symptoms and signs for two months before function. A pass requires the ability to resuming Safety Critical Work. maintain balance while standing with shoes off, feet together side-by-side, eyes closed and arms by sides, for thirty seconds.
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MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – VESTIBULAR DISORDERS
CONDITION CRITERIA Vestibular The criteria for Fit for Duty are not met: Function • If the person has, or has had in the previous twelve months, any condition of recurrent vertigo. This includes confirmed Meniere's disease, recurrent unheralded vertigo and/or benign paroxysmal positional vertigo, with or without treatment, or any other type of vertigo. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ENT specialist and the nature of the work: • For persons who have had vertigo caused by Meniere's condition, or recurring unheralded attacks of vertigo, after at least twelve months free of vertigo; • For persons who have had one episode of vertigo caused by acute labyrinthitis (deafness and vertigo), acute neurolabyrinthitis (vestibular neuronitis), after at least six months free of vertigo; • For persons who have any other type of vertigo, after at least two months free of vertigo; • For persons who have had BPPV only, after at least two months free of symptoms and signs of BPPV. The ENT Specialist is to have regard to: • The nature of the condition and response to treatment; and • The functional ability to perform Safety Critical Work such as drivers entering/exiting the cab in an emergency.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms that could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Mckiernan D, Jonathon D 'Driving and Vertigo' Clinical Edwards FC, McCallum RI, Taylor PJ 'Fitness for work: The Otolaryngology, 2001, 26, 1-2. medical aspects' Joint Report of the Royal College of Physicians and the Faculty of Occupational Medicine, Oxford University Press, 1988.
Code of Practice for Health Assessment of Rail Safety Workers 79
22. VISION AND EYE DISORDERS
22.1 RELEVANCE TO SAFETY Signallers may be required to rapidly and CRITICAL WORK accurately identify all signal lights in the event of signal failure occurring. Good vision is essential to Safety Critical Shunters may need to identify all colours Work as visual information is crucial to including purple although the trains they are operating machinery and walking about as guiding are generally moving slowly. required by work. Any marked loss of visual acuity or visual field will diminish an Flagmen need to identify red/yellow/green individual’s ability to work safely. A worker flags and be able to interpret signal lights as with a significant visual defect may fail to warning of an oncoming train. detect another train or member of the public and will take appreciably longer to perceive Signal repairers need to recognise red/green and react to a potentially hazardous situation. at a distance from a single lens signal to check correctness of their repairs and to Colour vision is a particular issue in the rail ensure safety of the network. However they industry because coloured signals can give are not under time pressure to read the signal. crucial information about safety to proceed, the speed to proceed and the route. The following jobs illustrate typical colour vision Diagram 9. Evaluation Process for Colour requirements but they are not necessarily Vision correct for any one network. Risk assessments of the colour vision requirements 1. External/Outdoor Rail Safety Work) of jobs are required and should be done in conjunction with a specialist in occupational medicine to determine the appropriate classification and hence examination. Where Is accurate response to “reds” variations are made from the national essential for rail safety? standards they should be identified to all (need distinguish red/yellow/green) parties because they have implications for NO YES portability. The full details on risk assessment for jobs is given in a separate Guideline on Risk Assessment; but the guidance on colour vision follows: No colour Is there sufficient redundancy 15 vision in safety systems that failure to Evaluation Process for Colour Vision requirement recognise red will not affect There are two main groups of jobs regarding safety (eg. positional cues of colour vision; external work and work involving traffic lights or of semaphore multicolour screen based equipment. arms, 2 drivers always present, speed is always low, etc)? The process for evaluation is illustrated in Diagram 9. YES NO Persons who are Colour Vision Normal have normal colour vision on testing on the Ishihara tests, whereas those who are No colour Is it necessary to recognise Colour Defective Safe are not normal but vision “reds” under extreme can distinguish red/green with time and requirement conditions eg. high speed, poor may work in jobs where quickness or visibility? distance etc is not crucial in signal recognition. NO YES Train drivers generally require good colour vision. Positional cues are not always Requires ‘Colour Requires ‘Color available as red-green lights may operate from Vision Defective Safe’ Vision Normal’ a single lens signal; lights from a signal may have no background or illumination at night to help their identification; there may be dazzle 2. Screen based equipment from a low sun behind the signal; and red lights may be shone from a lantern in Work on screen-based equipment with multicolours requires minimal ‘CV Defective Safe B’1 emergency situations requiring rapid reaction. Combinations of red/yellow/green signals are 1 used to inform the train driver of a safe speed CIE Technical Report: recommendations for colour vision requirements for transport. CIE 143-2001 and routing.
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22.2 MEDICAL CRITERIA FOR SAFETY necessary to ensure adequate overall fields of CRITICAL WORKERS vision. (Refer to Musculoskeletal Disorders.) Visual fields may be initially screened by Medical criteria for fitness for duty are outlined confrontation. Any person who has or is in the table overleaf. suspected of having a visual field defect There may be a degree of flexibility allowed at should be referred for expert assessment by the optometrist's or ophthalmologist's an optometrist or ophthalmologist. As a discretion for individuals who barely meet minimum, a central (30 degree) visual field visual standards but who are otherwise alert, should be measured using an automated have normal reaction times and good static perimeter (Humphrey Field Analyser, muscular coordination. Medmont M700, Octopus). If the automated perimetry (on repeat) suggests that the criteria The two most important aspects of vision in for fitness for duty are not met then Goldman relation to Safety Critical Work are: or Esterman perimetry should be performed. • visual acuity Binocular vision is required for all Safety • visual fields Critical Work. Controllers who require only a Visual acuity: limited field of vision may be exempted. For the purposes of these Standards, visual Colour vision: acuity may simply be defined as the best The flow chart on page 109 summarises the obtainable vision with or without glasses or testing procedures for the levels of colour contact lenses. Visual acuity should be vision. measured with one eye occluded and without correction. If correction is normally used when Colour vision should be screened using working then vision should be retested with Ishihara plates; two or more errors/12 plates is corrective lenses and the corresponding a fail. NOTE: No colour lenses or sun glasses results recorded. Acuity should be tested to be used when testing. using an appropriate visual acuity chart Drivers and signallers who fail do not meet the (Snellen chart or equivalent). Alternative criteria but may be offered a practical test. charts (for example, Landolt Ring, tumbling E) may be used for persons who cannot read Practical tests of colour vision may be English characters. considered for drivers (and others) who fail the ordinary medical examinations. However the Persons who require glasses to perform duties test is not intended to imply any relaxation of should be classed as Fit for Duty subject to the standard for colour vision. Railway review and reviewed at an appropriate time systems can differ in important details interval depending on the underlying regarding signal systems requirements. condition. Therefore, it is not sensible or safe to apply a NOTE: It is not required that workers carry uniform practical test nationally. These notes spare sets of glasses at work. However outline the principles of conducting a test persons who wear contact lenses must carry a within a particular railway. The results of such spare set of glasses in case a foreign body a test are not necessarily valid for any other enters the eye (so requiring removal of the railway because signalling systems may vary lens). NOTE: In the case of corneal surgery, between States and networks. The test corneal pathology or a cataract, acuity should should be conducted by persons be assessed with a dilated pupil in the knowledgeable of the work. presence of a glare source. Principles of Practical Tests for Colour Vision Visual fields: • Driving a typical train (~80-130km/hr) and Adequate visual fields are important for Safety interpreting signals requires a person to Critical Work and peripheral vision is be “Colour Vision Normal”, which is particularly important in certain common defined as less than 2 errors//12 plates driving tasks, such as use of side mirrors on an Ishihara test. (Shunters and drivers (which are important for monitoring the of heritage trains may be further tested integrity of the train). Visual fields may be using the Farnsworth Lantern and reduced as a result of head trauma, brain persons who are “Colour Defective Safe” tumour, stroke or cerebral infarction. may be passed for these jobs.) Persons Visual field losses also occur in eye diseases who fail may be offered a practical test such as retinitis pigmentosa, a not uncommon using the following principles which are inherited degeneration of the retina that mainly relevant to drivers. causes significant visual field loss by the age • The test should be based on the ability to of 30. Conditions such as glaucoma, optic read a variety of “multiple aspect” signals atrophy, retinal detachment and localised typical of those encountered on the retinal or choroidal infection can also reduce system. The test will need to be designed visual fields. Good rotation of the neck is also by experienced engineers/ drivers in conjunction with colour vision experts.
Code of Practice for Health Assessment of Rail Safety Workers 81
• The test should be conducted at the screened with Ishihara plates; two or more maximum distance a driver would be errors/12 plates is a fail. Workers who fail expected to interpret the signals. The should be tested by Medmont C100 and those maximum distance is required as a proxy who are protans are Unfit for Duty, those who for poor visibility in rain, glaring sunshine, are deutans should be tested with Farnsworth etc. The test should be conducted by day Lantern and those who pass are Fit for Duty. and by night. (All drivers on main lines are required to be • A control subject should to be selected. colour vision normal). Their colour vision status must be known ATTP do not require colour vision testing. to be “CV normal” based on a recent Ishihara test, so they are a valid control. Tram drivers do not require red and green colour vision. This is consistent with the latest • Test subject and control should be briefed Austroads standard for commercial vehicle on the test. drivers. Tram driving is comparable to bus • The test involves a series of random driving in terms of risk and similar standards showings of at least 10 signals at a should be applied. frequency and duration designed to simulate the requirements of the system. Dark Adaptation: Health professionals may wish to recommend restrictions on workers • The subject must obtain a score similar to who appear to meet the visual criteria in the the control to pass. clinical setting but may, in certain • If the subject passes they may be environments have extreme difficulty. permitted to drive only on the rail system Examples of such restrictions might be for which they have passed the practical daylight driving only, where certain disorders test. If they wish to drive on another or diseases such as retinitis pigmentosa can system, a practical test for that system cause poor night vision, or distance and/or must be conducted. speed restrictions. • In the event of a Signal Passed at Danger Progressive Eye Conditions: Workers with (SPAD) the driver may be required to a progressive eye condition such as cataract, repeat the test. glaucoma, diabetic retinopathy, optic • If the person has another eye disorder neuropathy and retinitis pigmentosa should be (eg impaired acuity) that condition should counselled that their eye condition will or may be carefully monitored. progress to a stage where they are no longer able to work. They should be encouraged to Alternatively drivers who fail the colour vision consider making lifestyle changes in test may be referred to a clinic specialising in anticipation of not being able to work. Their colour vision and its relevance to public safety. vision should be monitored regularly. Information on the complexity of the signalling Because persons with cataract suffer loss of system and the worst-case situations in which contrast sensitivity and greater sensitivity to signal recognition is required should be glare, they may have more difficulty seeing supplied at the time of referral. The results when working than is indicated by their visual only apply to the signal system about which acuity. the information was supplied. Short-term Eye Conditions and Eye Shunters, flagman and signal repairers who Treatments: Persons whose vision is fail should be tested by Medmont C100. temporarily disturbed by a short term eye Those who are protans are Unfit for Duty, condition or an eye treatment should be those who are deutans should be tested with counselled not to perform Safety Critical Work Farnsworth Lantern (or equivalent eg Optec for a specified time or to limit their work during 900CV Tester) and those who pass are Fit for this time. This includes temporary patching of Duty (colour defective safe A). any eye, the use of mydriatics or drug known Train controllers who work with multicolour to affect vision, and after eye surgery. (they screen-based equipment need to distinguish should be classed as Temporarily Unfit for colours such as red, magenta, blue and green Duty) which may be difficult for dichromats. They Congenital and Acquired Nystagmus: The should be screened with Ishihara plates; two criteria for visual acuity must be met and any or more errors/12 plates is a fail. Workers underlying condition fully assessed. who fail should be further tested with Farnsworth D15 test three times. A pass is Diplopia: Workers suffering from all but two or more correct trials which identifies minor forms of diplopia generally are unsafe to “Colour Defective Safe B”. An incorrect trial is drive. Any person who reports or is suspected two or more errors on the test. of experiencing diplopia should be referred for expert assessment by an optometrist or Heritage and Tourist train drivers who are not ophthalmologist. They should be classed as on a main line usually have a semaphore arm Temporarily Unfit for Duty pending review. on a signal which gives a positional cue as well as a red/green light. They should be
82 Department of Infrastructure
COLOUR VISION REQUIREMENTS AND TESTING FOR RAIL SAFETY WORKERS
PASS Fit for Duty ISHIHARA (Colour vision normal) Colour Vision Normal TEST Fail ≥ 2 errors/ NOT Fit for Duty 12 plates Refer for practical test or FAIL Colour Vision Clinic
PASS Fit for Duty DEUTAN FARNSWORTH (Colour Defective Safe A) ISHIHARA PASS Fit for Duty Colour Defective TEST (Colour vision normal) LANTERN TEST Safe A NOT Fit for Duty Fail ≥ 2 errors/ NOT Fit for Duty Refer for practical test or 12 plates MEDMONT C100 FAIL Refer for practical FAIL Colour Vision Clinic TEST test or Colour Vision PROTAN Clinic
ISHIHARA PASS Fit for Duty (Colour vision normal) Colour Defective TEST PASS Fit for Duty (Colour Defective Safe B) Safe B Fail ≥ 2 errors/ 12 plates FARNSWORTH D15 FAIL TEST NOT Fit for Duty Refer for practical test or Colour FAIL Vision Clinic
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MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – VISION AND EYE DISORDERS
CONDITION CRITERIA Acuity Visual acuity should be measured one eye at a time (monocularly), without correction in the first place. Acuity should be tested using a standard visual acuity chart (Snellen chart or equivalent) that includes at least five letters on the 6/9 and 6/18 lines. Alternative charts (for example, Landolt Ring, tumbling E) may be used for persons who cannot read the alphabet. More than two errors in reading the letters of any line is regarded as a failure to read the line. The criteria for Fit for Duty are not met: • If the person's visual acuity is worse than 6/9 in the better eye; or • If the person's visual acuity is worse than 6/18 in either eye. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ophthalmologist or optometrist or GP, and the nature of the work: • If the standard is met with corrective lenses; and • After consideration of the stability of any underlying disorder. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ophthalmologist or optometrist, and the nature of the work: • If the person's vision is worse than 6/18 in the worse eye, provided that the visual acuity in the better eye is 6/9 or better; and • After consideration of the nature of any underlying disorder. In cases of latent nystagmus made manifest by the occlusion of one eye for the purpose of testing, a binocular visual acuity of 6/9 is acceptable if the visual acuity of the better eye is below 6/9 with occlusion of the fellow eye. The same minimum standard of vision in the worse eye applies.
Colour vision Drivers and signallers: These standards Colour vision should be screened using Ishihara plates; more than one error/12 may be varied plates is a fail. subsequent to a The criteria for Fit for Duty for drivers and signallers are not met: risk assessment of the network • If the person is not Colour Vision Normal, that is, does not pass the Ishihara test. and on advice of a specialist in Drivers and signallers who fail the Ishihara test do not meet the criteria, but may occupational be further assessed for confirmation at a colour vision clinic. medicine. Flagman, shunters and signal repairers: Colour vision should be screened using Ishihara plates; more than one error/12 plates is a fail. Shunters, flagman and signal repairers who fail the Ishihara test should be tested by Medmont C100 and those who are protans are not Fit for Duty; those who are deutans should be tested with Farnsworth Lantern and those who pass are Fit for Duty. The criteria for Fit for Duty for flagman, shunters and signal repairers are not met: • If the person is a protan or deutan as determined by the Farnsworth Lantern test (ie they must be Colour Defective Safe A). Train controllers: Colour vision should be screened using Ishihara plates; more than one error/12 plates is a fail. They should be further tested using Farnsworth D15 test. The criteria for Fit for Duty for a train controller are not met: • If the person consistently fails the Farnsworth D15 test (ie they must be Colour Defective Safe B).
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MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS – VISION AND EYE DISORDERS
CONDITION CRITERIA Colour vision Heritage and Tourist train drivers: (continued) Colour vision should be screened using Ishihara plates; more than one error/12 plates is a fail. Historical train drivers who fail the Ishihara test should be tested by Medmont C100 and those who are protans are not Fit for Duty, those who are deutans should be tested with Farnsworth Lantern and those who pass are Fit for Duty. The criteria for Fit for Duty for historical train drivers are not met: • If the person is not Colour Defective Safe A, that is, a protan or deutan as determined by the Farnsworth Lantern test. Tram drivers No colour vision standard
Diplopia The criteria for Fit for Duty are not met: • If the person experiences any diplopia (other than physiological diplopia) when fixating objects within 20o of the primary direction of gaze.
Night blindness No specific standard. Refer general management guidelines in text (Paragraph (Dark adaptation) 22.2 – Dark Adaptation). Visual Fields Visual fields may be initially screened by confrontation. Any person who has or is suspected of having a visual field defect should be referred for expert assessment by an optometrist or ophthalmologist. Central visual fields should be measured using an automated static perimeter (Humphrey Field Analyser, Medmont M700, Octopus.). If the automated perimetry (on repeat) suggests that the criteria for fitness for duty are not met then Goldman or Esterman perimetry should be performed. The criteria for Fit for Duty are not met: • If the person has any visual field defect. • If the person is monocular (see text). Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ophthalmologist or optometrist, and the nature of the work:
• If the binocular visual field has an extent of at least 140o within 20o above and below the horizontal midline; and • If the person has no significant visual field loss (scotoma, hemianopia, quadrantanopia) that is likely to impede work performance; and • After consideration of the stability of any underlying disorder.
ATTP For vision criteria for ATTP refer PART 2B of this Volume.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions that may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case-by-case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms that could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
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References Colour Vision 9. Hager, G., Das Sehorgen und das Unfallgeschehen im Strassenverkehr. Klin. Mbl. 1. Vision and Driving. Department of the Augenheilk 142:427-433 1963 Environment, Transport and the Regions 12/12/2001 10. Cole, BL and Brown, B (1966) Optimum intensity of red road-traffic signals lights for normal and 2. Council Directive of 29 July 1991 on driving protanopic observers. J. Opt Soc Amer 56: 516- licences (91/439/EEC) The Council of the 522 European Communities. 11. Cole, BL and Vingrys, AJ (1983b) Do protanomals 3. Pape vs CAA 1985, Denison vs CAA 1989 have difficulty seeing red lights? Proc CIE 20th Administrative Appeals Tribunal Session, Amsterdam, 1983. Guideline 56, E04, 4. Vingrys A.J., Cole B.L., Are colour vision CIE Paris, 1-3 standards justified for the transport industry? 12. Nathan, J, Henry, GH and Cole, BL (1964) Ophthal. Physiol. Opt.,1988, Vol.8,July Recognition of coloured road traffic light signals 5. Owsley C., Vision impairment and driving Survey by normal and color-vision-defective observers. J Ophthal.43,6 May Jun 1999 Opt Soc Amer 54: 1041-1045 6. Norman L.G., Medical aspects of road safety. 13 Favilla I.,Visual Requirements for drivers licences Lancet 1, 989-994 1960 RACO 7. Verriest et al.: New investigations concerning the 14. Hovis and Oliphant (2000) A lantern colour vision test relationships between congenital colour defects for the rail industry. Am J Ind Med, 38 (6); 681-96) and road traffic security. Int. Ophthal. 2: 87-9 15. CIE Technical Report: recommendations for 8. Cole B.L., Vingrys A.J.:Reply to the report colour vision requirements for transport. CIE 143- 'Review of the research basis for the current 2001 medical standards for colour vision (Protan deficits)' Soames Job, R.F.
Visual Fields 6. Lovsund P and Hedin A. Effects on driving performance of visual field defects. In: Gale AG et 1. See Charman WN. Vision and driving – a literature al, editors. Vision in Vehicles. Amsterdam: Elsevier; review and commentary Ophthal Physiol Optics 1986: 323-329. 1997; 17: 371-391, and North RV. The relationship between the extent of visual field and driving 7. Keeney JL. The relationship between ocular performance – a review Ophthal Phyiol Optics pathology and driving impairment Am J Ophthalmol 1985; 5: 205-210. 1976; 82: 799-801. 2. Johnson CA and Kelttner JL. Incidence of visual 8. Liesmaa M. The influence of drivers vision in field loss in 20,000 eyes and its relationship to relation to his driving ability Optician; 1973: 166, 10- driving performance Arch Ophthalmol 1983; 101: 13. 371-375. 9. Edwards MG and Schachat AP. Impact of 3. Fishman GA, Anderson RJ, Stinson L and Haque enucleation for choroidal melonoma on the A. Driver performance of retinitis pigmentosa performance of vision dependent activities Arch patients Brit J Ophthalmol 1981; 65: 122-126. Ophthalmol 1991; 109: 519-521. 4. Elkington AR and MacKean JM. Glaucoma and 10. McKnight AJ, Shinar D and Hilburn B. The visual driving Brit Med J 1982; 285: 777-778. and driving performance of monocular and binocular heavy truck drivers Accid Anal Prev 5. Wood JM and Troutbeck R. Effect of restriction of 1991; 23: 225-237. binocular visual field on driving performance Ophthal Physiol Optics 1992; 12: 291-298. 11. Ivers RQ, Mitchell P, Cumming RG. Sensory Impairment and Driving: the Blue Mountain Study. Am J Public Health 1999; 89: 85-87.
Further reading Higgins, K.E., Wood, J., Tait, A., Vision and driving: Steward, J.M., and Cole, B.L., What do colour vision selective effect of optical blur on different driving tasks, defectives say about everyday tasks? Optometry and Human Factors, 40(2), 224-232, 1998. Vision Science, 66(5), 288-295, 1989. Soames Job, R.F., Review of the research basis for the Westlake, W., Another look at visual standards and driving, current medical standards on colour vision (Protan deficits), BMJ, 321, 972-973, 2000. Report to Licensing and Policy Projects, Roads and Traffic Authority of NSW, June 2001.
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PART 2B: MEDICAL CRITERIA FOR AROUND THE TRACK PERSONNEL Full visual fields and good acuity are important to Rail safety workers who are within the safety envelope sense an oncoming train. but not in a Controlled Environment require a health assessment. There are appreciable risks from There must be sufficient soundness of limb to permit moving trains which can be surprisingly quiet even at rapid movement away from a train. high speed so the ability to hear a train horn is important. A horn is intended to emit about 88dB at Workers who access the track receive Track Safety 200m in the country and 85dB at 100m in towns. The Awareness training on a regular basis. standards have been set with a wide margin of safety Frequency of Assessment: The Track Safety to allow for adverse environmental conditions and Health Assessment for Category 3 (ATTP not in a the worker facing away from the train. Controlled Environment) should be conducted at: Note: workers who are at any time working directly • time of commencement and change of grade on the track should be regarded as functionally deaf • age 40 and five yearly thereafter. and blind. A hearing standard for their safety is not Workers should be advised that if they incur serious appropriate and they require suitable track injury or illness to their eyes, hearing or limbs, they protection. Also this hearing standard and testing should report to their supervisor for a Triggered should not be confused with the requirements for Health Assessment. audiometric monitoring required by OHS regulations for noise-exposed workers.
MEDICAL CRITERIA FOR TRACK SAFETY HEALTH ASSESSMENT
CONDITION CRITERIA Vision Visual acuity should be measured one eye at a time (monocularly), without correction in the first place. Acuity should be tested using a standard visual Acuity acuity chart (Snellen chart or equivalent) that includes at least five letters on the 6/9 and 6/18 lines. Alternative charts (for example, Landolt Ring, tumbling E) may be used for persons who cannot read the alphabet. More than two errors in reading the letters of any line is regarded as a failure to read the line. The criteria for Fit for Duty are not met: • If the person's visual acuity is worse than 6/9 in the better eye; or • If the person's visual acuity is worse than 6/18 in either eye. Fit for Duty Subject to Review may be recommended if: • The standard is met with corrective lenses; and • After consideration of the nature of any underlying disorder. Fit for Duty Subject to Review may be recommended if: • The person's vision is worse than 6/18 in the worse eye, provided that the visual acuity in the better eye is 6/9 or better; and • After consideration of the nature of any underlying disorder. In cases of latent nystagmus made manifest by the occlusion of one eye for the purpose of testing, a binocular visual acuity of 6/9 is acceptable if the visual acuity of the better eye is below 6/9 with occlusion of the fellow eye. The same minimum standard of vision in the worse eye applies. Fit for Duty Subject to Job Modification may be considered, for example if the worker is to be escorted at all times when around the track.
NOTE: It is not required that workers carry spare sets of glasses at work. However workers who use contact lenses should have a set of glasses for use lest a foreign body prevents use of contact lens.
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MEDICAL CRITERIA FOR TRACK SAFETY HEALTH ASSESSMENT CONDITION CRITERIA Vision Visual fields may be initially screened by confrontation. Any worker who has or is suspected of having a visual field defect should be referred for expert Visual Fields assessment by an optometrist or ophthalmologist. Visual fields should be measured using an automated static perimeter (Humphrey Field Analyser, Medmont M700, Octopus). If the automated perimetry suggests that the criteria for Fit for Duty are not met then Goldman or Esterman perimetry should be performed. The criteria for Fit for Duty are not met: • If the person has any visual field defect. • If the person is monocular Fit for Duty Subject to Review may be recommended: • If the binocular visual field has an extent of at least 140o within 10o above and below the horizontal midline; and • If the person has no significant visual field loss (scotoma, hemianopia, quadrantanopia) that is likely to impede work performance; and • After consideration of the nature of any underlying disorder. Fit for Duty Subject to Job Modification may be considered, for example if the person is to be accompanied at all times when around the track.
Hearing Compliance with the standard should be assessed by conducting audiometry, without aids in the first place.
The criteria for Fit for Duty are not met: • If the worker has an unaided average hearing threshold level of equal to or greater than 40dB in the better ear. (Average hearing threshold is the simple average of pure tone air conduction thresholds at 500, 1000, 2000 Hz). Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ENT specialist and the nature of the work: • If a practical test is passed (refer Chapter 10). Fit for Duty Subject to Job Modification may be considered, for example if the worker is to be escorted at all times when around the track.
Refer to Chapter 10 for considerations with respect to use of hearing aids.
Musculoskeletal The criteria for Fit for Duty are not met: Disorders • If chronic pain or restriction of joint movement or amputation of the lower limbs interferes with the ability to rapidly move from an oncoming train: Fitness for Duty Subject to Periodic Review may be recommended, taking into account the opinion of a specialist and the nature of the work: • If the condition is under adequate treatment. Fitness for Duty Subject to Job Modification may be considered, for example if the person is to be accompanied at all times when around the track.
Alcohol, Drugs If at time of examination a person appears to be mentally impaired they should be assessed per the procedures for Drug and Alcohol impairment (refer to Diagram 10).
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Diagram 10. Periodic Health Assessment - Management of possible impairment due to alcohol or drugs (illicit and prescription/OTC)
Is there evidence of impairment? Preliminary Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, attitude, comprehension). YES NO
Discuss with worker No further action Is there a medical basis for impairment, ie a (continue with health medical condition causing impairment or assessment) prescription medication or OTC drug taken for a Y ES defined purpose. NO
Medical basis If suspect alcohol or illicit drug use
• Classify Temporarily Unfit for Duty. • Classify Temporarily Unfit for Duty and • If appropriate, discuss medication with advise on report impairment without clear medical basis. GP/treating doctor in order to resolve impact on employment. • Contact employer regarding impairment • If appropriate, refer to relevant chapter without clear medical basis and await for medical conditions. further instructions from employer.
• Identify review period.
Temporary Illnesses. This Code does not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
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PART 3: CASE STUDIES These studies illustrate the application of medical standards and the decision process for assessing rail safety worker fitness for duty. They begin with a typical scenario and then consider the issues arising for the participants. The cases include a description of the tasks of the worker and the health requirements for these tasks. The descriptions are typical of the rail safety tasks in question but are not representative of all rail organisations. The rail organisation will provide a task description for each rail safety worker presenting for health assessment.
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1. Case Study 1: Train Driver on Commercial Network presenting for Periodic Health Assessment
Driver in cab - right hand on power/ Driver climbing steep ladder deadman's handle. to locomotive.
Driver checking underneath rolling stock. Driver cleaning window of cab.
Drivers may be required to undertake a wide range of tasks depending on the locomotive and network.
Disclaimer: these photos are of healthy persons taken in the course of their work and do not imply any connection to the case study.
1.1 Presentation Lou is a 53-year-old train driver who attends for his periodic High Level Safety Critical Worker (Category 1) Health Assessment. His last assessment five years ago reported him Fit for Rail Safety Duty. He considers himself fit and well, does not regularly attend the family doctor. He takes no medication.
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1.2 Task Description and Health Requirements
ACTIVITIES AND WORKING CONDITIONS: HEALTH ATTRIBUTES:
The train driver’s job involves a variety of Health requirements relating to the safety tasks that include: of the rail network: • Continuous skilled driving to meet a • Good physical and psychological health timetable, which involves: in order to maintain vigilance when - sitting for long periods while reading driving; instruments; • Normal colour red-green perception in - communicating by radio or signal order to read signals and flags; telephone to a signaller or train • The ability to focus readily at changing control in a noisy environment; distances and lighting levels (such as - operating handles to brake and entering a tunnel) to see signals or other accelerate the train; signs; - constant vigilance to detect and respond to colour (red and green) • Good eyesight to read data on a flat signals in a variety of changing screen/SBE to monitor the train; conditions; and • Psychological ability to memorise and - scanning the track ahead for retain route and signal placement; unexpected events and responding • Good hearing and speech to communicate accordingly. on radio and communication devices and • Working a rotating shiftwork roster; the ability to discern communications in a • Performance of tasks outside the cab in noisy environment. (There is also a need all types of weather, ground conditions, to understand written information. This is and times of day or night including: not a medical issue but should be - climbing in and out of the crew cab; addressed at pre-placement through - checking the integrity of the train; other means); - coupling carriages in a confined • Sufficient musculoskeletal strength and space; flexibility to be able to: walk externally - fixing faults involving kneeling along the length of the train on uneven bending and reaching, using the ground (ballast); to correctly un/couple signal telephone; and carriages including heavy coupling - changing points. devices such as air hoses, electrical • Emergency response including: jumpers and emergency couplers in - exiting the cab to the ground in awkward spaces; unpredictable conditions such as after • If there is an incident the driver must be an accident; and able to get out of the cab and walk - walking distances to provide distances on uncertain terrain in protection of the site. unpredictable weather and light, and take emergency measures to protect safety of the rail network. Health requirements relating to the safety of the worker: Covered above
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1.3 Documentation • Safety Critical Worker Health Questionnaire (completed by Lou); • Safety Critical Worker Health Assessment Request and Report Form (completed by Lou’s employer); • Report of previous Health Assessment; • Safety Critical Worker Health Assessment Record (provided by employer for completion by examining health professional); • Audiometry result forwarded to health professional by provider; • Cholesterol (total and HDL), blood glucose and ECG results forwarded to authorised health professional by pathology provider.
1.4 Assessment At the health assessment the authorised health professional notes that Lou smokes 30 cigarettes per day, has a family history of heart disease (his father died at 56 from a heart attack) and is overweight. He gives no history of chest pain or shortness of breath. He admits he does not exercise regularly any more and that he has gained quite a bit of weight in the past year since his wife left him. Upon examination it is noted that he has a resting blood pressure of 180/110mmHg, his total cholesterol is 7.0 and HDL 0.91, his resting ECG is normal and he has no diabetes. The cardiac risk score is calculated to be 28, which is above the cut-off score of 22.
Cardiac Risk Score Calculation Data Score Age/sex Male, 53 11 Smoker: Y/N Y 4 Blood Pressure (see above) 180/110mmHg 6 ECG (left ventricular hypertrophy) Normal 0 Fasting cholesterol – TOTAL 7.0 4 – HDL 0.91 3 Fasting plasma glucose (diabetes) 5.3 0 TOTAL SCORE 28
1.5 Action Authorised Health Professional The authorised health professional diagnoses a raised cardiac risk score that requires referral to a cardiologist for detailed assessment (for example, treadmill, thallium scan). Since Lou is asymptomatic and the cardiac score is less than 32 he may continue to drive but should be seen soon after the cardiologist’s report is received. The authorised health professional advises Lou’s general practitioner of his findings and alerts him to the need for risk factor modification. The authorised health professional discusses the findings with Lou, explaining the possible concern about his heart and the need for prompt referral for more tests and attention to his lifestyle. Lou is told that the health professional will recommend he is Fit for Duty Subject to Review but if Lou experiences chest pains he must stop driving immediately, see his general practitioner and tell his supervisor.
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The authorised health professional completes the report to the employer, indicating Fit for Duty Subject to Review and noting that referral to a specialist has been made. The health professional indicates that Lou should be seen at the practice within the next month. Lou asks the health professional who is going to pay for these tests as Lou does not have health insurance. The health professional advises Lou to discuss this with his employer but that it is likely that his employer will pay for the diagnostic tests required to ascertain his fitness to drive (stress test, thallium scan, echocardiogram and visits to cardiologist) but will not pay for tests/procedures that are regarded as treatment for his condition (such tests include coronary angiogram, stenting, heart surgery). Employer On receipt of the report, the employer enters Lou’s details into the rail organisation’s recall system and flags him for review in a month. One Month Later Authorised Health Professional The cardiologist advises that Lou has a positive exercise test and that a thallium scan has revealed significant reversible myocardial ischaemia. Lou has been advised by the cardiologist that he will require an angiogram and cardiac surgery (either a stent or coronary artery bypass grafting). The authorised health professional tells Lou he will be unfit to drive trains for at least three months after the cardiac procedure and that he may not be able to return to driving duties in the long term. He emphasises the need to address lifestyle issues with support from his general practitioner. The authorised health professional advises the employer that Lou is Temporarily Unfit for Duty as a loco driver. Lou is however fit for alternate duties. Employer On receipt of the final report, the employer discusses employment options with Lou. There is a vacancy due to maternity leave at the local station. As he remains well, Lou is happy to fill this position in preference to staying at home on sick leave.
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2. Case Study 2: Train Controller presenting for Triggered Health Assessment
Controller of country trains plotting Controller in metropolitan area Controller of metropolitan network following movement of trains on using a bank of screens with multi- movements of trains. a board (distant) and screens (to colours to track train movements. his left).
Disclaimer: these photos are of healthy persons taken in the course of their work and do not imply any connection to the case study.
2.1 Presentation Serge is a 45-year-old train controller who attends the rail organisation’s authorised health professional for a Triggered Health Assessment as a result of concerns regarding recurrent sick leave. Serge is a Category 2 Safety Critical Worker and his last assessment was four years ago at which the doctor reported him as Fit for Rail Safety Duty. Serge smokes 40 cigarettes per day and is overweight.
2.2 Task Description and Health Requirements
ACTIVITIES AND WORKING CONDITIONS: HEALTH ATTRIBUTES: Operators in a network control room set and Health requirements relating to the safety monitor the progress of suburban trains. of the rail network: • They receive information about problems • Good physical and psychological health arising from passengers, track or the train to be alert, particularly in emergencies and make any necessary routing when decisions may be made that could decisions. jeopardise the safety of the rail network; • They make safeworking decisions • The ability to distinguish colours on multi- regarding operation of the network. An coloured screens as well as adequate incorrect decision could lead to a serious vision for SBE work; incident on the rail network. • Hearing and speech the same as an • They are in voice communication with office worker to communicate on radio drivers and others; monitor progress of devices. trains on banks of screens. Health requirements relating to the safety • They operate in an open plan area and of the worker: have shift rosters that include night shifts. None • The work may be routine but it can be stressful (for example, if a storm causes signal faults or trees across lines).
(cont)…
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ACTIVITIES AND WORKING CONDITIONS: HEALTH ATTRIBUTES: • In emergency situations experienced supervisors support individuals and help coordinate the response. In an emergency normal safety controls may be overridden which could lead to errors affecting the safety of the rail network. • Colours may be used on the computer screens to identify tasks or activities that require particular attention by the controller.
2.3 Documentation • Safety Critical Worker Health Questionnaire (completed by Serge); • Safety Critical Worker Health Assessment Request and Report Form (completed by Serge’s employer), including attendance record summary indicating that Serge has taken twenty sick days in the past six months - all of one to two days’ duration. Some were accompanied by a doctor’s certificate for a medical condition; • Report of previous Health Assessment; • Safety Critical Worker Health Assessment Record (provided by employer for completion by examining health professional).
2.4 Assessment On review of Serge’s Safety Critical Worker Health Questionnaire, the authorised health professional finds the K10 questionnaire gives a score of 35. On further questioning, Serge reports having problems at home. His wife has a gambling problem, their financial situation is poor and their fifteen-year-old son has been in trouble with the police.
K10 Questionnaire QUESTION SCORE 6.1 In the past 4 weeks, about how often did you feel tired out for no good 5 reason? 6.2 In the past 4 weeks, about how often did you feel nervous? 4 6.3 In the past 4 weeks, about how often did you feel so nervous that 4 nothing could calm you down? 6.4 In the past 4 weeks, about how often did you feel hopeless? 3 6.5 In the past 4 weeks, about how often did you feel restless or fidgety? 4 6.6 In the past 4 weeks, about how often did you feel so restless you could 3 not sit still? 6.7 In the past 4 weeks, about how often did you feel depressed? 4 6.8 In the past 4 weeks, about how often did you feel that everything was 2 an effort? 6.9 In the past 4 weeks, about how often did you feel so sad that nothing 3 could cheer you up? 6.10 In the past 4 weeks, about how often did you feel worthless? 3 TOTAL SCORE 35/50
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His wife is worried that he appears to stop breathing at night. He is constantly tired, has no energy and admits that on a couple of occasions recently he has “nodded off” whilst at the control panel. His Epworth Sleepiness Scale (ESS) (in the Safety Critical Worker Health Questionnaire) score is 16/24. He is due to work as a train controller that evening.
Epworth Sleepiness Scale QUESTION SCORE 4.1 Have you ever had, or been told by a doctor that you had NO a sleep disorder, sleep apnoea, or narcolepsy? 4.2 Has anyone noticed that your breathing stops or is YES disrupted by episodes of choking during your sleep? 4.3.1 Sitting and reading 3 4.3.2 Watching TV 2 4.3.3 Sitting, inactive in a public place (eg. a theatre or meeting) 3 4.3.4 As a passenger in a car for an hour without a break 2 4.3.5 Lying down to rest in the afternoon when circumstances 2 permit 4.3.6 Sitting and talking to someone 1 4.3.7 Sitting quietly after a lunch without alcohol 2 4.3.8 In a car, while stopped for a few minutes in the traffic 1 TOTAL SCORE 16/24
2.5 Action Authorised Health Professional The authorised health professional diagnoses significant anxiety, mild depression (history and raised K10, ≥ 19) and probable sleep apnoea (history and ESS score, ≥ 16). These conditions, undiagnosed and untreated, are incompatible with undertaking the train- controlling task safely. Serge is referred for a sleep study and his general practitioner is contacted to arrange management of his anxiety and depression. The authorised health professional discusses with Serge that he has an anxiety state that requires referral to his general practitioner and a probable sleep disorder that requires urgent investigation. The health professional counsels Serge that he is Temporarily Unfit for Duty as a train controller and is to be reviewed again in one month after the test results are to hand and the anxiety state is treated. He advises Serge that his employer provides a free Employee Assistance Program to workers and their families and that this might help him with his family difficulties. The authorised health professional contacts Serge’s supervisor immediately by phone as Serge was scheduled to work that evening. He advises that Serge is temporarily unfit for rail safety work (as a train controller) but indicates Serge may be fit for clerical work. He does not provide details of Serge’s medical condition but indicates that Serge will be referred to a specialist and to his general practitioner. The authorised health professional completes the report and indicates that he will review Serge in a month’s time. Employer The supervisor makes immediate changes to the roster and arranges to see Serge to discuss alternative duties. He enters Serge’s details into the rail organisation’s recall system and flags him for review within a month’s time.
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One Month Later Authorised Health Professional At review in one month the sleep specialist report advises that Serge has confirmed sleep apnoea and has had a good response to treatment. A letter from Serge’s general practitioner indicates that Serge has been diagnosed with significant depression. He has been referred to a psychologist and has been commenced on paroxetine, the dose of which has recently been increased to 40mg. His wife has been referred to Gambler’s Anonymous. At this stage, Serge is considered at risk of being impaired by the new dose of anti-depressant, so he is not yet considered fit to return to Safety Critical Work. The authorised health professional advises Serge’s supervisor that Serge is not yet ready to return to work as a train controller but is fit for alternate duties. Further review is planned in one month’s time. One month later - second review Authorised Health Professional Serge’s treating doctor has advised that Serge is progressing well. His mood has improved and he is stable on 40mg of paroxetine. He has not reported any drowsiness and his doctor is aware of the Drug Legislation for Transport Workers. The situation at home is improving. As a result, the authorised health professional is of the opinion that Serge is fit to return to work as a Train Controller, but intends to monitor his progress by reviewing him in 3 months. Employer The supervisor notes the report results and flag’s Serge for a Triggered Health Assessment in 3 month’s time and arranges for Serge to return to work as a Controller.
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3. Case Study 3: Signaller presenting for Periodic Health Assessment
Signaller pulling levers for points and signals
3.1 Presentation Jack is a 48-year-old signaller who attends for his periodic Safety Critical Worker (Category 2) Health Assessment. His last assessment five years ago reported him fit for rail safety duty. He considers himself fit and well. He does not regularly attend the family doctor and takes no medications.
3.2 Task Description and health Requirements
ACTIVITIES AND WORKING CONDITIONS: HEALTH ATTRIBUTES:
Signallers are responsible for the control of Health requirements relating to the safety trains through a section of track. of the rail: • They monitor the progress of the train • Good physical and psychological health to from a large display board set at a be continually alert and make appropriate distance above them and activate points decisions; and signals by switches or by • Normal colour vision to read signals in the pulling/releasing levers. The action may event of signal failure; be repeated up to twice a minute at peak hours and requires appreciable strength • Adequate vision to read a computer of arms, back and legs. screen/SBE as well as distance vision; • Signallers may need to access the track • Hearing and speech as an office worker to to give a written rail pass to a driver. communicate on radio devices. • In the event of a signal failure they may Health requirements relating to the safety need to access the track and correctly of the worker: identify red/yellow/green colours from a Covered above single lens signal.
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3.3 Documentation • Safety Critical Worker Health Questionnaire (completed by Jack); • Safety Critical Worker Health Assessment Request and Report Form (completed by Jack’s employer); • Report of previous Health Assessment; • Safety Critical Worker Health Assessment Record (provided by employer for completion by examining health professional); • Audiometry results, forwarded by provider.
3.4 Assessment At the health assessment the authorised health professional notes that Jack smokes, is obese and he has glycosuria +++ on urine testing. He has no history of diabetes but advises that his father is a non-insulin dependent diabetic. He has no ocular, cardiac or peripheral vascular symptoms associated with diabetes.
3.5 Action Authorised Health Professional The authorised health professional diagnoses that Jack probably has diabetes, though without complications at present. The authorised health professional refers Jack to his general practitioner for fasting plasma glucose and other tests to confirm a diagnosis of diabetes. The health professional writes a referral letter to the general practitioner and telephones on the day with Jacks consent to explain the situation. He alerts the general practitioner to the fact that Jack works shifts and this should be considered when discussing his diet/medication. Close liaison with the general practitioner is required. The authorised health professional discusses the finding of probable diabetes with Jack and the need to see his general practitioner soon and to comply with treatment to help ensure his continuing fitness for duty. He advises Jack that he is being assessed as Fit for Duty Subject to Review and that he will be in touch with his general practitioner. The finding of glycosuria alone does not preclude rail safety work. The authorised health professional completes the report form advising the employer that Jack is Fit for Duty Subject to Review. He should be reviewed in one month’s time to determine the outcome of his investigations with his local doctor. Employer The employer records the details of the recommendations and arranges a review assessment with the authorised health professional in one month’s time. General Practitioner Jack is examined by his general practitioner who finds he has a fasting plasma glucose of 24mmol per litre. This level is unlikely to be managed with diet alone and referral to a specialist is required. The general practitioner provides the employer with a doctor’s certificate indicating Jack is Temporarily Unfit for Safety Critical Work. He refers Jack to an endocrinologist and a dietician and reports these actions to the authorised health professional. The authorised health professional follows up the endocrinologist, providing background on Jack’s job requirements as a Safety Critical Worker and alerting the endocrinologist to the medical standards for rail safety workers. The relevant diabetic medical standards are photocopied and sent to the specialist for consideration in Jacks fitness for employment.
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Employer On receipt of the general practitioner’s report, the employer discusses the situation with Jack. He is able to provide alternative duties. Jack is advised to remain in alternative duties until the authorised health professional reviews the endocrinologist’s report. Specialist Jack is commenced on oral hypoglycaemic medication and dietary modifications. He is advised that the medication could alter his alertness until he has been stabilised. The medical criteria for Safety Critical Workers indicate that if the worker has Non-Insulin Requiring Diabetes Mellitus and is taking oral hypoglycaemic agents the criteria for fitness for Safety Critical Work are not met. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in diabetes or endocrinology, and the nature of the work: if the condition is well controlled and the patient compliant with treatment; and there is an absence of defined hypoglycaemic episodes as assessed by the specialist, the patient has awareness (sensation) of hypoglycaemia, and the worker is taking agents that provide the minimum risk of hypoglycaemia; and there is an absence of end organ effects that may affect rail safety work. One Month Later Authorised Health Professional The authorised health professional reviews the specialist reports. Jack has been commenced on an oral hypoglycaemic agent and dietary modifications. His blood sugar over the past week has been 8-10mmol per litre indicating good control. The specialist has advised that Jack’s condition is well controlled and that he is fit for Safety Critical Work Subject to Review according to the medical criteria. The authorised health professional advises the employer by telephone and forwards a completed report form. A recommendation for review one month after resuming his usual duties is made. If meals and shift work hours are a problem, the possibility of alteration of hours may be raised (Fit for Duty Subject to Job Modification). Jack however does not have problems with adjusting to shift work with his meals and his diabetic control is good. He produces a record of his self-measured blood sugars over the past month and his blood sugars have remained between 7-10 mmol per litre. Following review assessment the authorised health professional recommends that Jack is Fit for Duty Subject to Review. He recommends review every twelve months. This review will concentrate on the control of the diabetes. Jack will be required to produce a record of his blood sugar levels (diabetic control booklet) and he will be assessed for any signs of diabetic complications. Monitoring of his glycosylated haemoglobin is commenced. Jack is advised of this and that he will need to produce his booklet at each annual review. The recommendation Fit For Duty Subject to Review is completed and sent to the employer. Employer The employer records that Jack is to have an annual triggered review. 12 months later Authorised Health Professional Jack’s diabetic control continues to be satisfactory as evidenced by his diabetic record booklet, his gycosylated haemoglobin and history provided. He does not have problems with his medication, meals or shift work. He is considered to have stable, well-controlled diabetes. He requires ongoing annual triggered review by the authorised medical officer. The employer is advised of this and records that annual review is required.
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4. Case Study 4: Flagman presenting for Triggered Health Assessment
Inner flagman looking toward working party using heavy equipment on track.
Outer flagman putting detonators on track.
Disclaimer: these photos are of healthy persons taken in the course of their work and do not imply any connection to the case study
4.1 Presentation Alex is a 35-year-old flagman who has been referred for a Triggered Health Assessment due to a funny turn at work. Alex had his last periodic Safety Critical Worker (Category 1) Health Assessment three years ago at which he was reported Fit for Duty. This is a triggered referral from management.
4.2 Task Description and Health Requirements
ACTIVITIES AND WORKING CONDITIONS: HEALTH ATTRIBUTES:
Outer flagman Health requirements relating to the safety of the rail system: An outer flagman positioned at 2000m from the obstruction in country areas (1200m in • Good physical and psychological health metropolitan areas) places 3 Audible Track in order to maintain vigilance to detect Warning devices (ATWs or detonators) 10m and respond appropriately to train apart on the track and, whilst positioned at movements; least 40m from the ATWs, displays a Caution • Adequate visual acuity in order to be able signal to train Drivers. On hitting these to see near and far distances to detect ATWs, the Driver of an approaching train is train movement; required to bring the train under control and • Normal colour vision in order to be prepared to stop at the next hand signal distinguish red and green signals and location. operate flags; • Adequate hearing and speech to be able to communicate via signal phones, radios and at a distance to a workgroup.
(cont)… (cont)…
Code of Practice for Health Assessment of Rail Safety Workers 103
ACTIVITIES AND WORKING CONDITIONS: HEALTH ATTRIBUTES:
After passage of a train, the outer flagman Health requirements relating to the safety replaces the ATWs and resumes display of of the worker: the Caution signal in preparation for the next • The ability to integrate visual, sound and train. During periods of heavy traffic, vibration cues in order to detect an particularly in metropolitan areas, trains could oncoming train; be only a few minutes apart. • Physical mobility to move quickly out of The outer flagman is also required to remove the road of an approaching train; the ATWs from the track when directed by • Adequate visual fields to see out of the the site safeworking coordinator to allow corners of the eyes, as well as far- passage of a train from the other direction or distance (rather than reading-distance) at the end of the required protection period. sight to see train movement; An outer flagman may be required to operate • The ability to work at all times of day and alone in isolated locations for extended night in all types of weather and ground periods. conditions – especially walking distances on ballast (uneven ground). They are Inner flagman also required to stand for long periods of An inner flagman positioned at 200m from time. the obstruction displays a Stop signal unless directed otherwise by the site safeworking coordinator. The inner flagman must be positioned so that he can be seen clearly by the driver of an approaching train (who should be travelling at reduced speed expecting to stop) and be clearly visible from the worksite. Where both conditions cannot be achieved, additional intermediate flagmen may be positioned to ensure the required visibility in both directions. The site safeworking coordinator normally has radio or mobile phone contact with all the outlying members of the protection party but other means of communication such as visual or audible signals may also be used. Protection party duties may often rotated through other suitably qualified members of the site work group to help ensure high levels of vigilance are maintained throughout the protection period.
4.3 Documentation • Safety Critical Worker Health Questionnaire (completed by Alex); • Safety Critical Worker Health Assessment Request and Report Form (completed by Alex’s employer and indicating Triggered Health Assessment); • Report of previous Health Assessment; • Safety Critical Worker Health Assessment Record (provided by employer for completion by health professional).
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4.4 Assessment Alex advises the authorised health professional that he has had three funny turns over the past two years including a recent one at work. He has not been investigated or treated for these episodes. He states he gets no warning and cannot recall what happens. He thinks he is “out to it” for a few minutes, he cannot recall any injury such as bitten tongue or incontinence and he is just a bit sore generally when he recovers. He had a head injury five years ago with a fractured skull from a motorbike incident. He has no neurological or cardiac symptoms. At his previous Periodic Health Assessment his cardiac risk score was acceptable, the ECG normal and the AUDIT score was low. Clinical examination is essentially normal.
4.5 Action Authorised Health Professional Alex has an undiagnosed disorder (undifferentiated illness) that is predisposing him to sudden loss of awareness and this is not compatible with Safety Critical Work. The authorised health professional considers a wide range of disorders that may cause funny turns including drug or alcohol abuse.
Drug and Alcohol Impairment Assessment and Management
Is there evidence of impairment? Preliminary Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, attitude, comprehension). YES NO
Discuss with worker No further action Is there a medical basis for impairment, ie a (continue with health medical condition causing impairment or assessment) prescription medication or OTC drug taken for a Y ES defined purpose. NO
Medical basis If suspect alcohol or illicit drug use • Classify Temporarily Unfit for Duty. • Classify Temporarily Unfit for Duty and • If appropriate, discuss medication with advise on report impairment without GP/treating doctor in order to resolve clear medical basis. impact on employment. • Contact employer regarding impairment • If appropriate, refer to relevant chapter without clear medical basis and await for medical conditions. further instructions from employer.
• Identify review period.
If drug abuse is suspected the health professional may contact the employer and advise that Alex has an impairment for which a medical basis is not apparent. Then the employer may request Alex to have a urine test for drugs. Otherwise Alex would be referred to his general practitioner for investigation. The safety critical nature of his job would be emphasised to the general practitioner and to any specialist subsequently involved.
Code of Practice for Health Assessment of Rail Safety Workers 105
The authorised health professional considers a medical cause is likely and discusses his concerns with Alex and the need to see his general practitioner. He advises Alex that he is assessed as Temporarily Unfit for Duty and will see him after results of investigations are to hand. The health professional may also ask the employer if any of Alex’s workmates saw his turns and whether they can give any more information. The authorised health professional phones Alex’s supervisor to indicate that he is Temporarily Unfit for Duty pending further investigation. The specifics of Alex’s condition are not discussed but the health professional indicates that Alex has been referred to his general practitioner and may require specialist referral. He completes the report form and forwards it to the employer, advising that Alex is Temporarily Unfit for Duty but may perform Non-Safety Critical Work (where he can be seen by others if he becomes unwell). The report indicates that Alex will be reviewed in one month’s time. If no cause of the turns is found or they cannot be treated adequately then Alex would be Permanently Unfit for Duty as a Safety Critical Worker and alternative duties would need to be considered for him. Employer The manager records the requirement for review in one month’s time as well as Alex’s work restrictions. He is able to provide Alex with temporary non-safety critical alternative employment working in a Controlled Environment. General Practitioner and specialist Alex attends his general practitioner and undergoes initial blood tests and resting ECG. Because of his past head injury a possible neurological cause of the condition needs to be excluded. He is referred to a specialist neurologist. Results from EEG and MRI of the brain indicate that Alex has epilepsy. Medication is prescribed by the specialist and a report forwarded to the authorised health professional. One month later Authorised Health Professional It is important that the worker’s specific epilepsy syndrome and seizure types are identified so that an adequate evaluation of the person’s safety can be undertaken (including the risk of further seizures) and the appropriate therapy instituted. A full report will be required from the treating neurologist to assist in determining Alex’s long-term employment options. On review of the specialist report the authorised health professional advises Alex that he is Unfit to resume his High Level Safety Critical Work as a flagman. His employer is advised that this is a long-term restriction. Alex could work in maintenance work or other duties provided it is a Controlled Environment or that he is accompanied by others while working on the track. Employer Alex’s manager records this information and ensures Alex is not placed in Safety Critical Work. Alex is no longer a SCW or an ATTP who works in an Uncontrolled Environment. As a result he is not scheduled for any regular health assessments in future. If Alex’s epilepsy is stabilised over the next few years his job restrictions may be reviewed in conjunction with a specialist report particularly if he wishes to work as an ATTP in an uncontrolled environment. It is unlikely he would return to High Level Safety Critical work.
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5. Case Study 5: Tram Driver presenting for a Triggered Health Assessment
Tram driver with left hand on combined Trams travel on busy roadways. power/break/deadman's handle
Disclaimer: these photos are of healthy persons taken in the course of their work and do not imply any connection to the case study
5.1 Presentation Lee is a 35 year-old tram driver who has been referred for a Triggered Health Assessment due to increasingly unusual behaviour at work. It is known to the company medical officer that Lee has a history of bipolar disorder but has been stable for some considerable time on medication.
5.2 Description and Health Requirements
ACTIVITIES AND WORKING HEALTH ATTRIBUTES: CONDITIONS: The tram driver is required only to drive the Health requirements relating to the tram. Conductors dispense tickets. safety of the rail system: Drivers may be required to operate several • Good physical and psychological health types of trams that differ with respect to the to maintain vigilance when driving to types of controls and vigilance systems. protect the safety of the rail network; The driver usually controls the tram by using • Adequate level of fitness and dexterity to a console of buttons and switches plus hand enable driver be able to get out onto the levers and foot pedals. There may also be road, in the case of an emergency; side mirrors and video to aid internal and • Visual acuity and visual fields to ensure external views. safe operation of the tram; The driver is required to undertake • Normal colour perception is not continuous skilled driving to meet a regarded as essential for tram drivers. timetable. The main stress on the driver is They are similar to commercial vehicle the need to drive defensively in road traffic drivers who do not require red vision because a tram can only brake; it is not because red traffic lights give positional possible to take avoidance. cues. Also trams are usually on well-lit In the case of an emergency or incident the roads which enables detection of driver is required to get out of the tram and emergency signs. act to protect the safety of the network. The road is usually predictable and well lit. Health requirements relating to the safety of the rail worker:
Covered above.
Code of Practice for Health Assessment of Rail Safety Workers 107
5.3 Documentation • Safety Critical Worker Health Assessment Request and Report Form (completed by Lee’s employer and indicating Triggered Health Assessment); • Report of previous Health Assessment; • Safety Critical Worker Health Assessment Record (provided by employer for completion by health professional).
5.4 Assessment Discussion with Lee reveals obvious paranoid ideation and mood elevation. This is similar to previous episodes that have occurred in the past. The authorised health professional assesses that Lee is bordering on psychosis associated with his bipolar disorder.
5.5 Action Authorised Health Professional Lee is Temporarily Unfit for rail safety work pending review by Lee’s general practitioner and a psychiatrist. After explanation to Lee and with his consent, the health professional contacts Lee’s general practitioner by phone to arrange an urgent appointment. He also faxes a referral letter to the general practitioner requesting feedback on John’s progress. The authorised health professional also phones Lee’s supervisor to inform him of the situation with respect to John’s fitness for duty but does not discuss specific clinical details. He also informs the supervisor that Lee will not be fit to drive trams for a significant period of time although he may be fit for alternative duties and that further review before return to work is indicated. The health professional completes the health assessment report and forwards it to the supervisor. The health professional indicates that we will review Lee in 8 weeks. Employer The employer notes the recommendations and flags Lee for review in 8 weeks. 8 Weeks Later Lee’s treating specialist forwards a report to the authorised health professional recommending that Lee could be fit to return to work in some capacity. He reports that Lee has responded well to treatment, is compliant with medication and has no side effects from his new treatment regime. Authorised Health Professional At review, the authorised health professional advises Lee that due to the nature of his condition it will be significant period of time before he will be able to resume his driving duties, but he would be able to return to work assisting in office duties. Arrangements are made for further review at 6 and 9 months with further feedback from the treating specialist. It is explained to John that he may be able to return to driving duties thereafter if all remains stable. The authorised health professional advises the employer that Lee remains unfit to drive trams but that he could assist in office duties and that further review is planned at 6 and 9 months with a view to possibly returning to driving duties thereafter. Employer The employer notes the recommendations and arranges office duties.
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At 6 Months The treating specialist has indicated that Lee continues to be well and remains compliant with treatment. The authorised health professional advises the employer that Lee is stable but will need to remain stable for a further 3 months before resuming driving duties, but may continue alternative duties. At 9 Months The treating specialist again advises that Lee remains psychologically well, compliant and free from any medication side effects. Authorised Health Professional The authorised health professional advises Lee and his employer that he is fit to resume his full duties including tram driving but should be trailed with a senior driver. If this is satisfactory he will be required to have 3 monthly medical review for the first year. Employer The employer records that Lee is to have 3 monthly triggered review, arranges a practical driving assessment before recommencing him on normal driving duties.
Code of Practice for Health Assessment of Rail Safety Workers 109
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PART 4: MODEL FORMS
Code of Practice for Health Assessment of Rail Safety Workers 111
1. Safety Critical Worker Health Assessment
1.1 Safety Critical Worker Request and Report Form This form’s format allows for increased confidentiality and for inclusion of additional supporting information to be provided to the authorised health professional, for example, previous health assessment, Workcover and critical incident reports. The form is used as follows. 1. Part A: Employer completes Part A, encloses copies of relevant supporting information and a copy of the Health Assessment Record and forwards them to the examining health professional. 2. Part B: Health professional upon completion of the assessment, completes Part B of the form, retains a copy and returns the original form to the employer. 3. Part C: Employer completes Part C of the form. 4. Part D: Worker completes Part D of the form.
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THE COMPLETED FORM SHOULD BE RETURNED TO THE RAIL ORGANISATION A COPY SHOULD BE RETAINED BY THE HEALTH PROFESSIONAL
CONFIDENTIAL
Safety Critical Worker Health Assessment Request and Report Form (BLUE FORM)
IMPORTANT INFORMATION To the Employer " Please complete all relevant details in PART A of the form including: • Personal details of the worker. • Appointment details if appropriate. • A description of the rail safety duties to be performed by the worker. • The category of risk determined by the tasks and therefore the level of assessment (Category 1 or 2). • The type of assessment requested (eg. Pre-placement, Periodic, Triggered). • The pathology tests required (High Level Safety Critical Worker only). • Audiometry requirements. " Additional forms and information to be issued with this request include: • Safety Critical Worker Health Assessment Record to be completed and retained by the examining health professional. • Screen–based Equipment Request and Report Form and Assessment Record (if required). • Any additional information relevant to the assessment including copies of previous health assessment report, relevant Workcover reports, critical incident history and sick leave record. • Pathology request forms if required. " On receipt of the completed Health Assessment Report, please complete Part C and take action as appropriate. " Ask employee to complete and sign Part D as required in order to give permission to the health assessment result to be forwarded to another rail organisation. To the Health Professional " You are requested to conduct a health assessment to assess the worker’s fitness for rail safety duties according to the details provided in PART A of this form and according to Volume 2 of the Code of Practice for Health Assessment of Rail Safety Workers. " Please perform the assessment, complete PART B of this form and return to worker’s employer according to the instructions noted in PART A. " Category 1 High Level Safety Critical Workers are required to present for fasting cholesterol (total and HDL), fasting glucose and an ECG for preplacement and periodic assessments. This will have been arranged before the appointment with you and results will be forwarded to you directly. " Both Category 1 and Category 2 Safety Critical Workers are required to perform audiometry for preplacement, change of grade and periodic assessments. This will be arranged separately if audiometry facilities are not available at your practice. " Should the worker be assessed Unfit for Duty please contact the employer immediately by phone so that appropriate rostering changes may be made. " Details of the examination should be recorded on the enclosed Safety Critical Worker Health Assessment Record form. This record is confidential and should be retained by you, not returned to the employer. The employer’s chief medical officer (if they have one) may contact you for more information regarding the worker’s condition. " For more detailed information about the conduct of health assessments for rail safety workers see Volume 2 of the Code of Practice for Health Assessment of Rail Safety Workers.
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PART A – Employer to complete
1. Worker Details Family Name: First Names: Company: Location: Employee No: Date of birth: Supervisor: Phone: Facsimile: Account and report to be sent to Supervisor at the following address (Please insert postal address or fax number):
2. Medical Appointment Details: 5. Type of Assessment required Doctor: Pre-placement / Change of grade Health Assessment Address: Periodic Health Assessment Date: Time: Triggered Health Assessment (specify reason): 3. Description of Duties (or see attached ______Job Description or Task Risk Assessment) Drug Screen
Screen-Based Equipment Examination
Other (specificy): ______6. Risk Category/Level of Assessment
Category 1 (High Level Safety Critical Worker)
Category 2 (Safety Critical Worker) 4. Supporting information relevant to the assessment (tick information provided): Specific Health Requirements:
Colour vision Normal Previous relevant health assessment report(s) Colour Defective Safe A Relevant sick leave (number of days, not Colour Defective Safe B details): (SBE) ______Hearing Driver
Relevant Workcover history Non Driver / Other Musculoskeletal (note specific requirements): Relevant Critical Incident episodes ______
Positive Drug and Alcohol Assessment ______Reports 7. Tests Ordered: Record of involvement in serious rail safety Cardiac Risk Assessment (Category 1 only) incidents Fasting Cholesterol (total and HDL)
Fasting Plasma Glucose Other (specify): ______Resting ECG Drug Screen ______Pathology ordered from: ______Audiometry (Category 1 and 2) Audiometry ordered from: ______
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PART B – Health Professional to complete
I have sighted the worker’s photo ID I certify that I have examined the worker named in accordance with the medical standards contained in the Code of Practice for Health Assessment of Rail Safety Workers, Volume 2: Health Assessment Procedures and Medical Criteria and in my opinion the worker is (tick appropriate box):
Fit for Duty – Meets all relevant medical criteria. Local doctor referral Conditional on corrective lenses Conditional on hearing aid Other condition (specify): ______
Fit for Duty Subject to Review – Does not meet all I recommend: medical criteria, but could perform rail safety work if Review at this practice the condition is sufficiently under control and worker is more frequently reviewed than prescribed under DATE: periodic review. Specialist referral
Local doctor referral Company Medical Officer referral Laboratory tests
This certificate is valid until:
Fit for Duty Subject to Job Modification – Does not I recommend the following job modifications: meet all medical criteria, but could perform rail safety ______work if suitable modifications were made to the duties. ______
Temporarily Unfit for Duty Subject to Review – I recommend the following in terms of management Does not meet all medical criteria and cannot perform and review: current rail safety tasks but may perform alternative ______non-safety tasks. May return to full duty pending improvement in condition, response to treatment, ______confirmed diagnosis of undifferentiated illness. ______
Permanently Unfit for Duty – Does not meet the I recommend the following in terms of management medical criteria and cannot perform the job in the and review: future. ______
Health Professional Details (stamp acceptable) Name: Phone: Facsimile: Practice address: Signature: Date:
PART C – Employer to complete on receipt of Assessment Report Action taken as a result of Health Assessment: Job modification (details):______Triggered review (indicate period): ______Full periodic health assessment (details): ______Redeployment (details): ______Drug Assessment (details): ______
Part D – Worker to complete regarding portability of assessment result
I, ______(Print Name) give permission for this health assessment to be forwarded to another rail organisation as confirmation of fitness for duty.
Signature: ______Date: _____/_____/_____
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1.2 Safety Critical Worker Health Assessment Notification and Questionnaire
This form contains the Safety Critical Worker Health Assessment Notification and Safety Critical Worker Health Questionnaire as well as instructions for the worker.
The self-administered questionnaire is a screening tool to help identify conditions that might affect the performance of safety critical work. The questionnaire is not a diagnostic tool and no decision can be made regarding the worker’s fitness for duty until the full clinical examination is performed. The health professional may need to guide or assist with completion of the questionnaire if literacy or cultural background presents a barrier to self-administration by the worker. The health professional will also need to review the answers with the worker to ascertain relevant detail. Dishonest completion of the questionnaire may be an issue. Workers are required to sign the completed questionnaire in the presence of the examining health professional and the health professional should countersign.
The form is used as follows. 1. Part A: The employer requests that the worker sign the front of the form to indicate that they have read and understood the statements concerning the health information to be provided. 2. Part B: Worker completes PART B and presents to the health professional. The worker signs the form as a true statement and the health professional countersigns. 3. The employer discusses the results with the worker. The form is retained by the health professional and filed in the workers medical record.
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FOR PRIVACY REASONS THE COMPLETED FORM SHOULD BE RETAINED BY THE HEALTH PROFESSIONAL AND NOT RETURNED TO THE RAIL ORGANISATION
CONFIDENTIAL
Safety Critical Worker Notification and Health Questionnaire (PINK FORM) IMPORTANT INFORMATION To the Worker " You are required to attend a health assessment as a condition of your employment, to assess your fitness for undertaking rail safety work. " The health assessment must be completed by ______to ensure that you are able to carry out normal duties. " Complete the enclosed questionnaire BEFORE ATTENDING THE APPOINTMENT and provide it to the examining health professional " Take glasses, hearing aid or any other aids required for safety critical work to the appointment. " Take all medication that you are currently taking to the appointment or a list of such medications. " Take photo identification with you to the appointment. " If you are High Level Safety Critical Worker (Category 1) you will be required to have a blood test as part of your assessment. You will be required to fast (not eat) for 12 hours prior to the blood test. So as to get a true reading of your blood sugar and cholesterol (total and HDL) you should not eat for a minimum of 8hr (and no longer than 14hr) before your blood test appointment. You may drink water but should not take sweetened drinks. What if the examining doctor finds something you do not know about? If the examining doctor finds or suspects something is wrong with your health that you did not know about, they will ask permission to inform your own doctor. The examining doctor will not treat any medical condition but will give you a letter to take to your own doctor for treatment.
What happens after the health assessment? The details of your health assessment will remain confidential and will only be reported to your employer in terms of your fitness for duty. The examining doctor retains all detailed medical papers including your questionnaire responses, test results and the completed record of clinical findings. The examining doctor sends the completed ‘Request and Report Form: Safety Critical Worker Health Assessment’ directly to the referring railway organisation indicating your fitness or otherwise for duty.
No information will be disclosed to the employer or any other person or organisation without your written permission, except where: • a notifiable disease is diagnosed which must, by law, be reported to the State authorities • a report is subpoenaed by a court of law • the Secretary to the Department of Infrastructure (or another person) is required to conduct an inquiry into a railway accident or incident. If the report form indicates you do not meet all relevant medical criteria your supervisor at the rail organisation(s) will discuss the appropriate action to be taken. This may include: • modification to the duties that you undertake for that railway organisation • scheduling of a further review, tests or specialist referral Worker’s Declaration I, ______(Print Name) certify that I have read and understood the above statement concerning the Health Information provided herein.
Signature: ______Date: ______
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PART A – Employer to complete 1. Worker Details Family Name: First Names: Company: Location: Employee No: Date of birth: Supervisor: Phone: Facsimile: Account and report to be sent to Supervisor at the following address (Please insert postal address or fax number):
2. Medical Appointment Details: Doctor: Address: Date: Time:
3. Tests ordered: Pathology (Category 1 only Fasting Cholesterol (total and HDL Fasting Glucose Resting ECG
Instructions to worker: ______
Drug Screen
Instructions to worker: ______
______
______
Audiometry (Category 1 and 2)
Instructions to worker: ______
______
______
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120 Safety Critical Worker Model Notification and Health Questionnaire (Page 4 of 4) December 2003
1.3 Safety Critical Worker Health Assessment Record The model Health Assessment Record is a tool for health professionals to help guide the health assessment process. It provides a standard format for recording the results of the assessment which should then be filed by the examining health professional in the worker/patient’s medical history.
The form is used as follows. 1. Part A: Employer completes PART A, and includes the form with the Request and Report Form and forwards to the health professional. 2. Part B: Health professional records the results of the clinical examination in PART B and retains the form in the worker’s medical record. 3. The completed Health Assessment Record is not to be forwarded to the employer for reasons of privacy. The health professional should summarise the results in terms of fitness for duty on the Request and Report Form.
Code of Practice for Health Assessment of Rail Safety Workers 121
FOR PRIVACY REASONS THE COMPLETED FORM SHOULD BE RETAINED BY THE HEALTH PROFESSIONAL AND NOT RETURNED TO THE RAIL ORGANISATION
CONFIDENTIAL
Safety Critical Worker Health Assessment Record (GREEN FORM)
PART A Worker Details – Employer to complete Family Name: First Names: Company: Location: Employee No: Date of birth:
PART B Clinical Findings – Health Professional to complete and retain
1. Cardiovascular System: 2. Neurological/Locomotor:
1.1 Blood Pressure 2.1 Cervical spine rotation
Systolic mm Hg Normal ! Abnormal ! Diastolic mm Hg 2.2 Back movement
Normal ! Abnormal ! 1.2 Pulse Rate: Regular ! Irregular ! 2.3 Upper Limbs 1.3 Heart Sounds: a) Appearance: Normal ! Abnormal ! Normal ! Abnormal ! 1.4 Peripheral Pulses: b) Joint movements: Normal ! Abnormal ! Normal ! Abnormal ! ______2.4 Lower Limbs 1.5 Calculation of Cardiac Risk Score a) Appearance: (High level SCW examination only). Normal ! Abnormal ! See Cardiovascular chapter for scoring. b) Joint movements: Normal ! Abnormal ! Data Score Age/sex 2.5 Gait Normal ! Abnormal ! Smoker: Y/N 2.6 Romberg’s Test (A pass requires Blood Pressure (systolic) the ability to maintain balance while ECG (left ventricular standing with shoes off, feet together hypertrophy) side by side, eyes closed and arms by Fasting cholesterol – sides, for thirty seconds): TOTAL – HDL Normal ! Abnormal ! Fasting plasma glucose (diabetes) TOTAL SCORE
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3. Chest/Lungs: Normal ! Abnormal ! 9. Alcohol: Audit Questionnaire
(Record results from Question 5 of the Health Questionnaire) 4. Abdomen (liver): Normal ! Abnormal ! Question Score Question Score
Q 5.1 Q 5.6
5. Hearing, If required (Audiometry Q 5.2 Q 5.7 results): Q 5.3 Q 5.8
0.5 kHz 1.0 kHz 2.0 kHz Q 5.4 Q 5.9
Right Q 5.5 Q 5.10
Left TOTAL SCORE:
6. Vision: 10. Psychological Health:
10.1 K 10 Questionnaire 6.1 Visual Acuity (Record results from Question 6 of the Health Uncorrected Corrected Questionnaire)
Question Score Question Score R L R L 6/ 6/ 6/ 6/ Q 6.1 Q 6.6 Q 6.2 Q 6.7 Are contact lenses worn? No ! Yes ! Q 6.3 Q 6.8
6.2 Visual Fields (Confrontation to each Q 6.4 Q 6.9 eye): Q 6.5 Q 6.10 Normal ! Abnormal ! TOTAL SCORE: 6.3 Colour vision, if required
(Ishihara: ≥ 2 errors/12 plates is a fail) 10.2 Is attitude, speech and behaviour
Pass ! Fail ! appropriate? No ! Yes !
11. Medications:
7. Urinalysis (Record details of medications from Question 2 of the Health Questionnaire) 7.1 Protein: Normal ! Abnormal !
7.2 Glucose: Normal ! Abnormal !
8. Sleep: Epworth Sleepiness Scale
(Record results from Question 4 of the Health Questionnaire) Question Score Question Score Q 4.3.1 Q 4.3.5 Q 4.3.2 Q 4.3.6 Q 4.3.3 Q 4.3.7 12. Drug Screen (pre-placement or change Q 4.3.4 Q 4.3.8 of grade only): TOTAL SCORE: ______
Safety Critical Worker Health Assessment Record (Page 2 of 3) December 2003 123
RELEVANT CLINICAL FINDINGS AND ACTION Note Comments on any relevant findings detected in the questionnaire or examination, making reference to the requirements of the standard.
IMPORTANT: For privacy reasons, the completed Health Assessment Record must not be returned to the rail organisation. Please retain in the worker’s health record.
124 Safety Critical Worker Health Assessment Record (Page 3 of 3) December 2003
1.4 Screen-Based Equipment (SBE) Examination Request and Report Form Some Safety Critical Workers may perform duties which require them to perform a Screen- Based Equipment (SBE) Examination. This model form is designed for this purpose.
The form is used as follows. 1. Part A: Employer completes PART A and forwards to health professional together with the SBE Examination Record (See Model Form 1.5). Note:Health professional retains the Examination Record and does not return it to the employer. 2. Part B: Health professional summarises the results of the examination from the Examination Record in PART B and includes recommendations for corrective lenses. The Report Form is then sent to the employer. 3. Part C: Worker has the prescription filled and signs the declaration in PART C, should corrective lenses be prescribed specifically for SBE work.
Code of Practice for Health Assessment of Rail Safety Workers 125
THE COMPLETED FORM SHOULD BE RETURNED TO THE RAIL ORGANISATION
CONFIDENTIAL
Screen-Based Equipment Examination Request and Report Form (YELLOW FORM)
PART A - Worker Details – Employer to complete Family Name: First Names: Company: Location: Employee No: Date of birth: Supervisor: Phone: Facsimile: Account and report to be sent to (Please insert postal address or fax number):
PART B - Examination Report – Health Professional to complete and return to employer
Fit SBE work / does not require visual correction.
Fit SBE work / with current prescription.
Current prescription is not suitable for SBE work, therefore there is a need for lenses prescribed specifically for SBE work.
The person requires glasses prescribed specifically for SBE work, because of a visual problem that only arises with SBE work. I certify I have prescribed glasses that only need to be used for SBE work, as this employee does not need to use glasses for other visual tasks.
Provider Name:
Provider No: Phone:
Provider Signature: Date:
The above section must be completed by the Optometrist prior to employee re-imbursement
PART C – Worker Declaration – Worker to complete I have obtained glasses specifically for SBE work as prescribed by this provider. Attached are: (a) The original itemised receipt (b) Health Benefit refund towards cost of glasses (if applicable) Signature: Date:
126 Screen-Based Equipment Examination Request and Report Form (Page 1 of 1) December 2003
1.5 Screen-Based Equipment Eye Examination Record for Health Professional This form guides the health professional in undertaking the SBE examination. The form should not be returned to the employer. The results should be summarised on the Request and Report form (Form 1.4).
Code of Practice for Health Assessment of Rail Safety Workers 127
FOR PRIVACY REASONS THE COMPLETED FORM SHOULD BE RETAINED BY THE HEALTH PROFESSIONAL AND NOT RETURNED TO THE RAIL ORGANISATION
CONFIDENTIAL
Screen-Based Equipment Eye Examination Record for Health Professional (ORANGE FORM)
PART A – Worker Details – Employer to complete Family Name: First Names: Company: Location: Employee No: Date of birth: Is a multi coloured screen used for Safety Critical Work?
PART B – Examination Report – Health Professional to complete and retain
No Yes 1. Does the worker wear glasses or contact lenses? Specify ______
2. Is there a history of eye disorders? Specify ______
3. Is external eye examination normal? Specify ______
4. Is Distance Visual Acuity (Snellen chart) normal? - Right (Fail is 2 or more errors in 6/9 line) - Left Specify ______
5. Is acuity at 45cm and 70cm (Times Roman Chart or equivalent) normal? - Right (Fail is 2 or more errors of 20 words of N6 or N12 respectively) - Left Specify ______
6. Is colour vision (where multi-coloured screens are used for safety critical work) normal? Ishihara test (fail is 2 or more errors/12 plates)
If abnormal conduct Farnsworth D15 – Normal? Specify ______
7. For OHN use: Pass Refer
8. Clinical Notes: (In the event of an abnormality being found which requires optical correction, please consider all other optical requirements of the job to be included in the lens prescription). ______Ref: Eyesight testing of users of screen-based equipment. NOHSC 1992
128 Screen-Based Equipment Examination Request and Report Form (Page 1 of 1) December 2003
2. Track Safety Health Assessment
2.1 Track Safety Health Assessment Request and Report Form The model Request and Report Form for the Track Safety Health Assessment allows for a greater confidentiality in handling health assessment reports.
The form is used as follows: 1. Part A: Employer completes PART A, encloses a copy of the Health Assessment Record and forwards to the examining health professional. 2. Part B: Upon completion of the assessment, the Health professional completes PART B of the form, retains a copy and returns the original form to the employer. Health professional also completes the Health Assessment Record (Form 2.2) and retains it. 3. Part C: Employer completes PART C of the form. 4. Part D: Worker completes PART D of the form.
Code of Practice for Health Assessment of Rail Safety Workers 129
THE COMPLETED FORM SHOULD BE RETURNED TO THE RAIL ORGANISATION
CONFIDENTIAL
Track Safety Health Assessment Request and Report Form (MAUVE FORM)
IMPORTANT INFORMATION To the Employer " Please complete all relevant details in PART A of the form including: • Personal details of the worker • Appointment details if appropriate • Description of the rail safety duties to be performed by the worker • Type of assessment requested.
" Upon receipt of the completed Health Assessment Report from the examining health professional, please complete Section C indicating the action taken, and ask employee to complete Part D as required.
To the Worker " You are required to attend a health assessment as a condition of your employment, to assess your fitness for undertaking rail safety work. " The health assessment must be completed by (date)______in order to ensure that you are able to carry out normal duties. " Please ensure that you: - Take glasses, hearing aid or any other aids required for rail safety work to the appointment. - Take all medication that you are currently taking to the appointment or a list of such medications. - Take photo identification with you to the appointment.
" The details of your health assessment will remain confidential and will only be reported to your employer in terms of your fitness for duty. " The examining health professional may ask your permission to speak to your GP. " You may be required to attend for audiometry test of drug screen before attending the health assessment.
To the Health Professional " You are requested to conduct a health assessment to assess the worker’s fitness for rail safety work in accordance with the details provided in PART A of this form and in accordance with Volume 2 of the Code of Practice for Health Assessment of Rail Safety Workers.
" Please perform the assessment, complete PART B of this form and return to worker’s supervisor according to the instructions in PART A. " Should the worker be assessed Unfit for Duty please contact the employer immediately so that appropriate rostering changes may be made. " Details of the assessment should be recorded on the enclosed Track Safety Health Assessment Record form. This record is confidential and should be retained by you, not returned to the employer. The employer’s chief medical officer may contact you for more information regarding the worker’s condition. " For more detailed information about the conduct of health assessments for rail safety workers see Volume 2 of the Code of Practice for Health Assessment of Rail Safety Workers.
130 Track Safety Health Assessment Request and Report Form (Page 1 of 3) December 2003
Part A – Worker Details – Employer to complete Family Name: First Names: Company: Employee No: Location: Date of Birth: Supervisor: Phone: Facsimile: Account and report to be sent to the supervisor at (Please insert postal address or fax number):
Health Assessment Appointment Details Date: Time:
Description of Duties (or attach Job Description or Task Risk Assessment)
Type of Assessment requested
Pre-placement / Change of Grade Health Assessment Periodic Health Assessment Triggered Health Assessment (specify reason): ______Drug Screen / Review results Screen Based Equipment Examination Other (specify): ______
Tests Ordered
Drug Screen
Instructions to worker: ______
Audiometry
Instructions to worker: ______
Track Safety Health Assessment Model Request and Report Form (Page 2 of 3) December 2003 131
PART B – Health Professional to complete
I have sighted the worker’s photo ID I certify that I have examined the worker named in accordance with the medical standards contained in the Code of Practice for Health Assessment of Rail Safety Workers, Volume 2: Health Assessment Procedures and Medical Criteria and in my opinion the worker is (tick appropriate box):
Fit for Duty – Meets all relevant medical criteria. Local doctor referral Conditional on corrective lenses Conditional on hearing aid Other condition (specify): ______
Fit for Duty Subject to Review – Does not meet all I recommend: medical criteria, but could perform rail safety work if Review at this practice the condition is sufficiently under control and worker is more frequently reviewed than prescribed under DATE: periodic review. Specialist referral
Local doctor referral Company Medical Officer referral Laboratory tests
This certificate is valid until:
Fit for Duty Subject to Job Modification – Does not I recommend the following job modifications: meet all medical criteria, but could perform rail safety ______work if suitable modifications were made to the duties. ______
Temporarily Unfit for Duty Subject to Review – I recommend the following in terms of management Does not meet all medical criteria and cannot perform and review: current rail safety tasks but may perform alternative ______non-safety tasks. May return to full duty pending improvement in condition, response to treatment, ______confirmed diagnosis of undifferentiated illness. ______
Permanently Unfit for Duty – Does not meet the I recommend the following in terms of management medical criteria and cannot perform the job in the and review: future. ______
Health Professional Details (stamp acceptable) Name: Phone: Facsimile: Practice address: Signature: Date:
PART C – Employer to complete on receipt of Assessment Report Action taken as a result of Health Assessment: Job modification (details):______Triggered review (indicate period): ______Full periodic health assessment (details): ______Redeployment (details): ______Drug Assessment (details): ______
Part D – Worker to complete regarding portability of assessment result
I, ______(Print Name) give permission for this health assessment to be forwarded to another rail organisation as confirmation of fitness for duty.
Signature: ______Date: _____/_____/_____
132 Safety Critical Worker Request and Report Form (Page 3 of 3) December 2003
2.2 Track Safety Health Assessment Record The model Track Safety Health Assessment Record is a tool to help guide authorised health professionals with the health assessment process. It provides a standard format for recording the results of the health assessment which should then be filed in the worker’s medical history. The completed Health Assessment Record is not to be forwarded to the employer for reasons of privacy. The health professional should summarise the result in terms of fitness for duty on the Request and Report Form.
Code of Practice for Health Assessment of Rail Safety Workers 133
FOR PRIVACY REASONS THE COMPLETED FORM SHOULD BE RETAINED BY THE HEALTH PROFESSIONAL AND NOT RETURNED TO THE RAIL ORGANISATION
CONFIDENTIAL
Track Safety Health Assessment Record (WHITE FORM)
PART A – Worker Details – Employer to complete Family Name: First Name: Company: Location: Employee No: Date of birth:
PART B – Examination Report – Health Professional to complete
1. Medical History (tick appropriate box) 4. Hearing (Audiometry results): No Yes
1.1 Do you have any serious illnesses? ! ! 0.5 kHz 1.0 kHz 2.0 kHz
1.2 Do you have any difficulty of vision? ! ! Right 1.3 Do you have any difficulty of hearing? ! ! Left 1.4 Do you have any difficulty walking? ! !
5. Drug Screen (pre-placement or change of grade 2. Neurological/Locomotor: only): 2.1 Cervical spine rotation ______Normal ! Abnormal !
2.2 Back movement Comment on any relevant findings detected in the Normal ! Abnormal ! Health Assessment, making reference to the requirements of the standard. 2.3 Upper Limbs a) Appearance: Normal ! Abnormal !
b) Joint movements: Normal ! Abnormal !
2.4 Lower Limbs a) Appearance: Normal ! Abnormal !
b) Joint movements: Normal ! Abnormal !
2.5 Gait Normal ! Abnormal !
2.6 Romberg’s Test (A pass requires the ability to maintain balance while standing with shoes off, feet together side by side, eyes closed and arms by sides, for thirty seconds): Normal ! Abnormal !
3. Vision:
3.1 Visual Acuity Uncorrected Corrected R L R L IMPORTANT: For privacy reasons, the 6/ 6/ 6/ 6/ completed Health Assessment Record
must not be returned to the employer. It Are contact lenses worn? No ! Yes ! should be retained in the patient record.
3.2 Visual Fields (Confrontation to each eye): Normal ! Abnormal !
134 Track Safety Health Assessment Record (Page 1 of 1) December 2003
3. Task Risk Assessment
The Task Risk Assessment is a template form designed to guide the process of risk assessment of rail safety tasks and serve as a documentation of the conclusions of task assessment. The completed form is recommended as an inclusion with the information provided to the examining health professional and it supports a clearer understanding of the tasks performed by the worker and the matching health requirements.
Code of Practice for Health Assessment of Rail Safety Workers 135
Rail Safety Worker Risk Assessment Template
RAIL SAFETY WORKER JOB:
ASSESSMENT RECORD:
WORKSITE INSPECTION Date Completed by:
JOB DESCRIPTION Date
CONTEXT:
TASKS: HEALTH REQUIREMENTS: Health requirements relating to the safety of the rail system:
Health requirements relating to the safety of the rail worker:
ENGINEERING AND PROCEDURAL ENVIRONMENT:
RISK ANALYSIS AND CATEGORISATION:
SPECIFIC HEALTH REQUIREMENTS:
136 Rail Safety Worker Risk Assessment Template (Page 1 of 1) December 2003
PART 5: ALCOHOL AND DRUG CONTROLS
In June 2002 the Transport Act 1983 was A maximum penalty of $1,200 for rail amended to provide for controls over the use safety workers may occur if they are of drugs by rail safety workers. The new found to carry out safety work while laws are in addition to existing laws for impaired by alcohol or drugs, refuse to alcohol control and rail oranisation’s policies be assessed for drug impairment or which necessitate a zero blood-alcohol refuse to provide blood or urine for an concentration. They make it an offence to impairment assessment. undertake rail safety work while impaired by In most cases, it is expected that drug any type of drug. impairment issues will be resolved by All rail safety workers are covered by the internal company processes. alcohol and drug controls whether an Case Study 1: Self Disclosure employee, contractor, subcontractor or volunteer. A rail safety worker advises a supervisor before commencing or Company Drug and Alcohol Control during a shift that he/she may be Procedures impaired by a drug. The worker does not start, or All accredited rail organisations are required immediately discontinues rail safety to have an adequate safety management work and contingency arrangements system which includes a drug and alcohol should be made by management. control program. This should include The worker is advised to consult their provisions for conducting preliminary breath own doctor or the authorised health tests and preliminary impairment assessments professional to certify whether they on a rail safety worker where there are are fit or unfit to perform rail safety work. reasonable grounds to believe they may have alcohol present in the system or be impaired The authorised health professional believes the worker is impaired by a by a drug. drug, indicates the worker is A protocol describing an approved framework Temporarily Unfit for Duty and for rail organisations to develop consistent identifies a review date. drug assessment processes for rail safety Management explores available sick work was published in the Government leave or alternative duties options for the rail safety worker. Gazette in June 2002. Case Study 2: Show Cause The focus of the drug assessment is not on A supervisor/manager has a the drug itself, as medications and drugs reasonable belief that a rail safety affect people in different ways. Rather, the worker may be impaired by drugs. focus should be on the on the impairment The worker is required to undertake a and the at risk behaviour of the rail safety preliminary impairment assessment worker. (PIA) to establish the reasonable belief. Reasonable belief is based on Each rail organisation should ensure that the a worker’s behaviour or appearance authorised medical officer is made aware of such as poor mental alertness, poor their procedures for assessment and physical coordination, or unusual counselling and/or disciplining workers found behaviour. in breach of the policies. The PIA conducted by the organisation’s trained authorised The main aim of the drug control laws is to officer and provides a show cause raise awareness within the industry about the assessment. It comprises an alcohol risks of drugs and some medications for rail breath test and a standardised safety work. However penalties for non procedure for observing behaviour and appearance and recording compliance can apply. Failure to do so can results. attract a maximum penalty of $200,000 for a rail organisation.
Code of Practice for Health Assessment of Rail Safety Workers 137
The PIA establishes the basis for a a person of any of his or her reasonable belief the worker is impaired and normal mental or physical the worker is referred to the authorised health professional for an alcohol and drug faculties. It may be a screen. This may constitute a Triggered substance in any form, Health Assessment. whether gaseous, liquid, solid The authorised medical officer classifies the or other and includes material, worker as Temporarily Unfit for Duty pending preparation, extract and the results of the screening test. admixture. The screening test performed by the The Minister for Transport has declared authorised health professional in line with the certain substances to be a drug for the organisation’s procedures, should be done to purposes of the Act and has published the Australian Standard, AS 308:2001 a list of drugs in the Government Gazette. Procedures for the Collection, Detection and Quantitation of Drugs of Abuse in Urine. The The list does not contain banned test does not need to be conducted to the substances. Rather, it includes drugs evidentiary standard described below and that have been proven to show that prescribed in the Transport Act 1983. given particular circumstances, impairment may be caused. Its primary Circumstances Involving a Formal Drug purpose is in the event of a prosecution, Impairment Assessment to provide prima facie evidence in a In exceptional circumstances the rail safety Court of Law in proving that a particular worker may be required to undergo a formal drug has the ability to cause impairment. drug impairment assessment as outlined in Drugs included on the scheduled list are: the Transport Act 1983. This is undertaken • drugs of dependence as defined in as a result of a serious matter such as in the Section 4 of the Drugs, Poisons and event of a notifiable rail occurrence (for Controlled Substances Act (1981) example, collision or derailment) and where and listed in Schedule 11 of that Act the PIA indicates likely impairment. • drugs listed in Schedule K of the The drug impairment assessment is Standard Uniform Schedule for undertaken by a specially trained Police Drugs and Poisons. These are Officer at a police station for the purposes of incorporated into the Drugs, possible prosecution. The worker may be Poisons and Controlled Substances referred to the police by the organisation’s Act (1981) by reference as the management, or may be taken into custody Commonwealth Standard and are for an assessment by a police officer substances which require a warning attending at the scene of a rail incident. as to their potential to cause The drug impairment assessment comprises drowsiness and possible effects on behavioural tests and usually a clinical driving or operating machinery screening test. The police can require the • deleterious substances are included worker to provide blood or urine samples to a by reference to Section 57 of the registered medical practitioner or health Drugs, Poisons and Controlled professional for the purposes of alcohol Substances Act (1981). This and/or drug screening. includes methanol, methylated The results of these tests will not be spirits and inhaled solvents, resulting accepted by a Court of Law unless they have from glue and petrol sniffing. been video taped and supervised respectively. This list is of likely interest to an This is an evidentiary standard. authorised medical officer and is Drugs Declared Under the Transport Act therefore reproduced below. Further 1983 general information about the drug controls may be found on the The Act defines a drug broadly as: Department of Infrastructure website at: any substance - - - that may www.doi.vic.gov.au/publictransportsafety temporarily or permanently deprive
138 Department of Infrastructure
Transport Act 1983 ORDER AS TO DECLARED DRUGS I, Peter Batchelor, acting under Section 93(1AA) of the Transport Act 1983, by this Order - (a) declare - (i) each of the substances specified in the Schedule to this Order; and (ii) any natural principle, any natural or synthetic derivative, any salt and any compound of those substances; and (iii) any preparation or admixture of those substances, active principles, salts or compounds; and (iv) any substance included in a class of drug specified in the Schedule to this Order; and (v) any deleterious substance as defined by Section 57 of the Drugs, Poisons and Controlled Substances Act 1981 to be a drug for the purposes of that Act.
The Schedule
Acetorphine Cyclohexanone (Ketamine) Dioxaphetyl Butyrate N-Acetylamphetamine 1-Chloro-1-Phenyl-2-Methylamino- Diphenhydramine Acetyldihydrocodeine Propane Diphenoxylate Acetylmethadol Chlorpromazine Diphenyl Pyraline N-Acetylmethylamphetamine Clemastine Dothiepin 6-Acetylmorphine Clobazam Doxepin Alprazolam Clomipramine Doxylamine Amitriptyline Clonazepam Dronabinol (delta-9- Amylobarbitone Clonidine Tetrahydrocannabinol) Amphetamine Clonitazene Droperidol Anileridine Clorazepate Dipipanone Azatadine Cocaine Ecgonine Baclofen Codeine Ephedrine Barbiturates Codeine N-Oxide Ethylmorphine 1,4-Benzodiazepines Codoxime N-Ethyl-1-Phenylcyclohexylamine Benzoxazocines Cyclizine Etonitazene Benzethidine Cyclobarbitone Etorphine Benztropine Cycloserine Etoxeridine Benzylmorphine Cyproheptadine Fenfluramine Bezitramide Cysteamine Fentanyl Bromazepam Dantrolene Flunitrazepam 4-Bromo-2,5- Desipramine Fluphenazine Dimethoxyamphetamine Desomorphine Flurazepam 4-Bromo-2,5- Dexchlorpheniramine N-Formylamphetamine Dimethoxymethylamphetamine Dextromoramide N-Formylmethylamphetamine 4-Bromo-2,5- Dextropropoxyphene Furethidine Dimethoxyphenethylamine Diacetylmorphine (Heroin) Gabapentin (Nexus) Diampromide Gemcitabine Brompheniramine Diazepam Glutethimide Buclizine Diethylpropion Haloperidol Buprenorphine N, N-Diethyltryptamine Harmaline Bufotenine Difenoxin Harmine Butobarbitone Dihydrocodeine Hydrocodone Butorphanol Dihydrohydroxymorphine Hydromorphone Cetirizine Dihydromorphine Hydroxyamphetamine Chloral Hydrate Dimenhydrinate 4-Hydroxybutanoic Acid (GHB) Chlordiazepoxide Dimenoxadol N-Hydroxy-3, 4- Chlormethiazole Dimepheptanol Methylenedioxyamphetamine Chlorpheniramine Dimethindene Hydroxyzine 1-Chloro-1-Phenyl-2-Aminopropane 2,5-Dimethoxy-4- Imipramine 2-(2-Chlorophenyl)-2- Methylamphetamine Ketobemidone (Methylamino)- N, N-Dimethyltryptamine Lamotrigine
Code of Practice for Health Assessment of Rail Safety Workers 139
Levocabastine Metopon Phenylpropanolamine Lorazepam Mianserin Phenyl-2-Propanone Lysergamide Mirtazapine Phenyl-2-Propanone Oxime Lysergic Acid Monoacetylmorphine Phenyltoloxamine Lysergic Acid Diethylamide Moramide Pholcodine Mazindole Morpheridine Pimozide Mebhydrolin Morphinan Piminodine Meclozine Morphine Piperidine Derivatives Including- Mecloqualone Morphine N-Oxide Allylprodine, Meprodine, Medazepam Morphinone Phenoperidine and Prodine Meprobamate Myrophine Piritramide Mepyramine Nalbuphine Pizotifen Mescaline Nicocodine Prazepam Metazocine Nicodicodine Prochlorperazine Methadone Nicomorphine Proheptazine Methaqualone Nitrazepam Promazine Methdilazine 7-Nitro-1,4-Benzodiazepines Promethazine Methocarbamol Noracymethadol Protriptyline Methorphan Norcodeine Properidine 4-Methoxyamphetamine Normethadone Propiram 4-Methoxymethylamphetamine Normorphine Propoxyphene 5-Methoxy- N, N-Diethyltryptamine Norpipanone Pseudoephedrine 5-Methoxy- N, N- Nortriptyline Psilocin Dimethyltryptamine Olanzapine Psilocybin Methoxyamphetamines Opium Quinalbarbitone 2-Methylamino-Propiophenone Oxazepam Risperidone (Methcathinone) OxycodoneOxymorphone Secbutobarbitone Methylamphetamine Papaveretum Temazepam Methyldesorphine Pentazocine Tetrahydrocannabinol Methyldihydromorphine Pentobarbitone Thebacon Methylenedioxy-Amphetamines Pericyazine Thebaine 3,4-Methylenedioxy-Amphetamine Perphenazine Thenyldiamine (MDA) Pethidine Thiambutene 3,4-Methylenedioxy-N- Phenelzine Thiethylperazine Ethylamphetamine Pheniramine Thiopropazate 3,4-Methylenedioxy-N- Phenylacylmorphan Thioridazine Methylamphetamine Phenadoxone Thiothixene (MDMA) Phenampromide Tramadol (3,4-Methylenedioxyphenyl)-2- Phenazocine Tranylcypromine Bromopropane Phencyclidine 1-[1-(2-Thienyl) Cyclohexyl] N-Methyl-1-(3,4- Phendimetrazine Piperidine Methylenedioxyphenyl)-2- Phenmetrazine Trifluoperazine Butanamine (MBDB) Phenobarbitone Trimeperidine 1-(3,4-Methylenedioxyphenyl)-3- Phenomorphan Trimeprazine Bromopropane Phenoperidine Trimipramine (3,4-Methylenedioxyphenyl)-2- Phentermine Triprolidine Propanone 1-Phenyl-2-Chloropropane Zolpidem Methylphenidate 1-(1-Phenylcyclohexyl) Pyrrolidine Zopiclone Methylphenobarbitone 1-Phenyl-2-Nitropropene
140 Department of Infrastructure
Glossary of Terms
1. Accredited Rail Organisation 7. Controlled Environment means a means a rail organisation accredited rail workplace such as a rail siding, as defined in the jurisdiction’s rail yard or workshop environment relevant rail safety legislation as a where a risk assessment has been Manager of Infrastructure and/or performed to identify hazards and Provider of Rolling Stock and/or implement controls to ensure that Operator of Rolling Stock. any person working in or transiting 2. Authorised Health Professional the area is not placed at risk from means a health professional typically moving trains. with a qualification in medicine or in Note: A Controlled Environment nursing with a post graduate excludes a workplace where qualification in occupational health maintenance works are performed nursing, who has been selected by on running lines over the commercial accredited rail organizations, on the rail system. basis of their compliance with the specified selection criteria, to 8. Electric Traction Infrastructure undertake rail safety worker health means equipment and systems assessments. associated with the supply and reticulation of electricity for traction 3. Around the Track Personnel purposes, but excluding elements of (ATTP) means persons required to civil infrastructure supporting or work on a railway where any aspect otherwise associated with the of the task they are undertaking is equipment or systems. “on or near the track” as defined in Definition 27, that is within three (3) 9. Employer means an accredited rail metres from the edge of the closest organisation that engages a rail rail when measured horizontally and safety worker, either as a paid at any level above or below the rail worker or volunteer. when measured vertically, unless in 10. Ensure means to take all reasonable a position of safety. ATTP excludes action insofar as controllable factors any rail safety worker who is classified will allow. as a Safety Critical Worker. 11. Interstate System means any railway 4. Civil Infrastructure means track system, or part thereof, designated formation and drainage (but excluding by its owner as a route to be used track, refer Definition 32), fixed for the movement of interstate traffic. structures beside, over or under the track, including supports for overhead 12. Mainline means the line normally electric traction equipment, supports used for running trains through and for signalling and telecommunications between locations. equipment but excluding those 13. May indicates the existence of an equipments. option. 5. Competence means the possession 14. Operator means the person or body of skills and knowledge and the responsible by reason of ownership, application of them to the standards control or management, for the required in employment. provision, maintenance or operation 6. Contractor means a person who is of trains, or a combination of these; engaged by or on behalf of any body or person or body acting on its behalf. that has been accredited under a 15. Organisation means an owner or an jurisdiction’s relevant rail safety operator or a person or a body that legislation to provide goods or is both owner and operator. services to such a body.
Code of Practice for Health Assessment of Rail Safety Workers 141
16. Owner means the person or body 21. Risk Analysis means a systematic responsible by reason of ownership, use of available information to control or management, for the determine how often specified construction and maintenance of events may occur and the magnitude track, civil and electric traction of their consequences. infrastructure or the construction, 22. Risk Assessment means the overall operation or maintenance of train process of risk analysis and risk control and communication systems, evaluation. or a combination of these, or a person or body acting on its behalf. 23. Risk Control means the process of decision making which involves the 17. Rail Network means a system of implementation of physical changes, railways whether interconnected or standards, policies and/or procedures not. for eliminating, reducing and/or 18. Rail Safety Worker is as defined in managing risk. Section 93 of the Transport Act 1983 24. Risk Management means the and for this Code includes an systematic application of employee, contractor, subcontractor management policies, procedures or volunteer performing work on a and practices to the tasks of railway or tramway system: analysing, evaluating and controlling • as a driver, second person, risk. trainee driver, guard, conductor, supervisor, observer or 25. Rolling Stock means any vehicle authorised officer; that operates on or uses a railway track, excluding a vehicle designed • as a signal operator, shunter or for both on- and off-track use when person who performs other not operating on the track. work relating to the movement of trains or trams; 26. Safety Critical Worker means a worker whose action or inaction, due • in repairs, maintenance, or to ill health, may lead directly to a upgrade of railway infrastructure, serious incident affecting the rail including for rolling stock or network. associated works or equipment; • in construction or as a look out 27. On or near the track means three for construction or maintenance (3) metres from the edge of the closest rail when measured • any other work that may be horizontally and at any level above included by regulation. or below the rail when measured 19. Railway means a guided system vertically, unless in a position of designed for the movement of rolling safety. stock which has the capability of 28. Serious Incident for the purposes of transporting passengers, freight or this Code means an accident or both on a track together with its incident that affects the public or the infrastructure and associated network resulting in: sidings. This includes a heavy railway, a light railway, an inclined • the death of a person; railway or a tramway, having a • incapacitating injury to a person; nominal gauge in each case not less • a collision or a derailment than 600mm, but excludes crane involving rolling stock that results type runways and slipways. in significant damage; 20. Risk means the combination of the • any other occurrence which frequency or probability of results in significant property occurrence and the consequences of damage. a specified hazardous event.
142 Department of Infrastructure
29. Shall is to be understood as 32. Track means the combination of mandatory. rails, rail connectors, sleepers, ballast, points and crossing and 30. Should is to be understood as non- substitute devices where used. mandatory, that is, advisory or recommended. 33. Train means one unit of rolling stock or two or more units coupled, at least 31. Signalling and one of which is a locomotive or other Telecommunications self-propelled unit. Infrastructure means signalling equipment and telecommunication 34. Tram means a vehicle that runs on equipment provided and used as rails on a highway, road or easement part of the safe working and specifically designated for use by a operating systems of the railway but tram or light rail vehicle and includes excluding supports for such a light rail vehicle. equipment. 35. Worker means a rail safety worker as defined in Definition 18.
Code of Practice for Health Assessment of Rail Safety Workers 143
Index
A Cardiomyopathy, Acquired Brain Injury 62 Dilated 36 Acute Myocardial Infarction (AMI) 31, 33 Hypertrophic 37 Acute Renal Conditions 68 Cardiovascular Diseases 29 Addison’s Disease 58 Cataracts 81, 82 Adrenal Disease 58 Cerebral Palsy 62 AIDS 57 Chemotherapy 28 Alcohol, Cocaine 42, 43 Binge Drinking 25 Cognitive Disorders 62 Dependence 24, 25 Colour Vision 80-85 and Diabetes 24 Complex Conditions 19, 24 and Epilepsy 24 Congenital Disorders, Heart 35 and Medication 24 Coronary Artery Bypass Grafting and Illicit Drugs 24 (CABG) 33, 35 AUDIT Questionnaire 24, 26 Cushing’s Disease 58 Impairment 24, 26 D Legislative Requirements 24 Deep Vein Thrombosis 31, 36 Amphetamines and Stimulants 42, 44 Dementia 57, 61, 62, 66 Anaesthesia 27 Diabetes, Aneurysm Repair 31 Controlled by diet alone 40 Aneurysms, Gestational 65 Abdominal and Thoracic 33 Non-Insulin Requiring Type 2 40 Berry 62 Insulin Requiring (both type 1 and 2) 40 Angina Pectoris 30, 33 Diabetic Retinopathy 82 Angioplasty 31, 33 Dilated Cardiomyopathy 36 Anticoagulant Therapy 30, 34 Diplopia 82, 85 Antidepressant Medication 73 Disability, Antihistamine Medication 45 of Cervical Region 59 Antihypertensive Medication 37 of Thoracolumbar Region 59 Antipsychotic Medication 66 Drinking, Apnoea, Sleep 72, 73 Behaviour 24 Around the Track Personnel Binge 25 (ATTP) 9, 14 Drugs – Illicit Alcohol and Drugs 88 Legislative Requirements 42 Hearing 88 Impairment 42 Musculoskeletal 88 Screening 43 Vision 87 Drugs – Prescription and OTC Arrhythmias 34 (See also individual drug classes) Arthritis 59 Legislative Requirements 45 Asthma 70 Impairment 45 AUDIT Questionnaire 24, 26 Screening 46 Authorised Health Professional 3, 4, 6 E B ECG Changes 36 Benign Paroxysmal Positional Vertigo Embolism, Pulmonary 31, 37 (BPPV) 78 Endocrine Disorders 58 Blackouts/Syncope 77 Epilepsy, Brain, and Alcohol 24 Surgery 62 Concurrent conditions 49 Tumours 28 Isolated seizure 48, 49 Bundle Branch Blocks 36 Medication non-compliance 49 C Recurrent Seizure 49, 50 Caesarean Section 65 Withdrawal of medication 49, 50 Cancer 28 Epworth Sleepiness Scale 98, 73, 74 Cannabis 42 F Cardiac, Fatigue 72 Arrest 31, 35 Forms 111-135 Defibrillator 31, 35 G Failure 36 Gastrointestinal Disorders 52 Pacemaker 31, 35 Glaucoma 81, 82 Risk Score 94, 29, 35 H Surgery 30 Head Injury 62, 62 Transplant 31, 36 Hearing Cardiac Risk 94, 29, 35 Train Drivers 54, 56 Tram Drivers 54
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ATTP 88 Diabetes Mellitus 40 Practical Tests 55 Nystagmus 78, 82, 84 Heart, O Block 36 Obstructive Sleep Apnoea 72, 73 Failure 36 Optic Neuropathy 82 Lung Transplant 31, 36 Over-the-counter (OTC) Drugs 45 Hepatic, Oxygen Therapy 70 Encephalopathy 52 P Failure 53 Pacemaker insertion 31 Transplant 53 Palliative Care 28 High Level Safety Critical Workers Parathyroid Disease 58 HIV / AIDS 57 Parkinsonism 63 Hyperemesis Gravidarum 65 Periodic Health Assessments 11 Hypertension 30, 37 Peripheral Neuropathy 61, 63 Hypertension, in Pregnancy 65 Phaeochromocytoma 58 Hyperthyroidism 58 Pituitary Disorders 58 Hypertrophic Cardiomyopathy (HCM) 37 Post Natal Depression 65 Hypoglycaemia 39 Post Surgery, Orthopaedic 59 Hypotension and Syncope 37 Post Thoracotomy 70 Hypothyroidism 58 Practical Tests I Hearing 88 Illicit drugs 42 Musculoskeletal 88 Insulinoma 58 Vision 87 Insulin Requiring Diabetes Mellitus Pre-placement Health Assessments 11 (types 1 and 2) 40 Prescription and OTC Drugs 45 Intellectual Impairment 61 Privacy Legislation 3 Intracranial, Psychiatric Disorders 66 Surgery 62 Pulmonary Embolism 31, 37 Tumours 28 Q Ischaemic Heart Disease 30 Quadrantanopia 85 J R Joints, Radiotherapy 28 Painful 59 Record Keeping 20 Replacement 59 Renal Calculus Disease 68 K Renal Failure 68, 69 K10 Questionnaire 97, 66 Respiratory Diseases 70 L Responsibilities and Relationships 5 Labyrinthitis 78 Respiratory Failure 70 Laryngectomy 70 Retinitis Pigmentosa 81, 82 Legislative Requirements S Alcohol 24 Safety Critical Health Assessment 9 Illicit drugs 42 Safety Critical Worker Questionnaire Prescription/OTC drugs 45 Safety Critical Workers Light-headedness, Pregnancy 65 Sedative Medication 72, 74 Limb Control 61 Seizures, Liver Transplant 53 Isolated 48, 49 M Recurrent 49, 50 Malformations, Vascular, of Brain 62 Seizure free periods 48, 49 Meniere’s Disease 78 Only in sleep 48 Metabolic and Endocrine Disorders 58 Sleep Disorders 72 Methadone (Illicit Use) 42, 44 Sleep Apnoea 72, 73 Multiple Sclerosis 61, 63 Specialist Referral Musculoskeletal Disorders 59 Speech 70 ATTP 88 Standard Drinks Requirements for Train driving 59 Strain Patterns 36 Requirements for Flagman duties 59 Stimulant Medication 73 Requirements for Shunting 59 Stroke 61, 63 Mydriatics 82 Subarachnoid Haemorrhage 61 Myocardial Infarct 31, 33 Suspected Angina Pectoris 30, 33 N Syncope/Blackouts 73, 72 Narcolepsy 73, 74 Syncope due to Hypotension 37 Neglects 63 T Neurolabyrinthitis 78 Temporary Illness Neurological Disorders 61 Thoracolumbar Region 59 Neuropathy, Peripheral 61, 63 Tourette’s Syndrome 61 Night Blindness 85 Tracheostomy 70 Non-Insulin Requiring Type 2 40 Track Safety Health Assessment 10
Code of Practice for Health Assessment of Rail Safety Workers 145
Transient Ischaemic Attacks 61, 63 Recurrent 79 Triggered Health Assessments Vestibular Disorders 78 Tumours, brain 28 Vision and Eye Disorders 80 ATTP 87 U Visual, Undifferentiated Illness Acuity 81, 84, 87 V Colour 80-84 Valvular Heart Disease 38 Dark adaptation 82, 85 Vasovagal and Autonomic Dysfunction 37 Diplopia 82, 85 Vertigo, Fields 81, 85, 88 Paroxysmal 78 Practical Tests 81
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Acknowledgments
The Project Team responsible for researching and developing this Code of Practice comprised: Jan Powning Project Manager, Department of Infrastructure Dr Bruce Hocking FAFOM. FAFPHM. FRACGP. Occupational Physician Fiona Landgren Principal Consultant, Communicating for Health
The Department of Infrastructure acknowledges the assistance provided by the following members of the Victorian and National Industry Reference Groups:
Dr Keith Adam Occupational Physician and Chief Medical Advisor, Queensland Rail Bruce Anderson Safety and Quality Manager, Works Infrastructure (EDI) Rob Blackwell Systems Manager, Works Infrastructure (EDI) Graeme Breydon Chairman, Puffing Billy Railway Rob Burrows Director, Office of Rail Safety, Department of Planning and Infrastructure, WA Brian Busch Manager Safety, Australian Rail Track Corporation Alex Claassens Assistant National Secretary, Rail Tram and Bus Union (Locomotive Division) Dr Michael Couch Occupational Physician, NSW Malcolm Davidson President, Association of Tourist Railways Trevor Dobbyn State Branch Secretary, Rail, Tram & Bus Union (Vic Branch) Kent Donaldson Exec Dir Transport Safety & Rail Safety Regulation, Min.of Transport NSW Warren Doubleday Council of Tramway Museums of Australasia Dr Tim Drew Chief Medical Consultant to TransAdelaide David Edwards Executive Manager Safety, Pacific National Greg Ford Director Rail Safety, Queensland Transport Tamsin Gepp Department of Infrastructure Dr John Glastonbury Executive Member, Heritage Rail Australia (NSW) and Chairman 3801 Ltd Allan Gordon Superintendent Safeworking and Training, Pilbara Rail Ian Grenfell President, Tasmanian Association of Tourist Railways Catherine Herriman Assistant Director Safety Strategy, Ministry of Transport, NSW Bryan Homann Council of Historic Railways and Tramways SA and Pichi Richi Railway Caroline Hudson National Manager Human Resources, Australian Railroad Group Jeff Jaraie Manager Rail Safety, Yarra Trams Andrew Killingworth Rail Transport Museum, (Tourist and Heritage Rail) NSW Brian McIntosh Department of Infrastructure Marc Marotta Secretary Rail, Tram & Bus Union, Locomotive Division Dr Andrew Marsden Chief Medical Consultant to Westrail Jessie Murray Communicating for Health Michelle Nation Connex Trains Marnie O’Brien Manager Injury Management Centre, Rail Infrastructure Corporation Adrian Ponton Manager System Safety, Freight Australia Philippa Rogers Secretary, Association of Rail Preservation Groups of WA Inc Dr Paul Rollason President, Association of Tourist Railways Queensland John Shalders Code of Practice Manager, Australasian Rail Association Geraldine Sharman Department of Infrastructure Graeme Silvester Manager Safety Systems and Accreditation, Queensland Rail Dr Tim Stewart Medical Advisor to TasRail Craig Tooke Executive Officer, Council of Tramway Museums Australasia Dr Stuart Turnbull National Express (Bayside) Keith Wheatley NRTC Project Manager Dr Anthony Webster Health Services Australia Julie Wills State Rail Authority of NSW Dr Paul Woodhouse Australian Medical Association (Victoria)
The following industry reference is also acknowledged:
Emerald Tourist Railway Board, Risk Analysis for Rail Safety Work at the Puffing Billy Railway, July 2003
Code of Practice for Health Assessment of Rail Safety Workers 147
Contact Information
Public Transport Safety Department of Infrastructure 80 Collins Street, Melbourne Victoria Australia 3000 Telephone: (03) 9655 8949 International: + 61 3 9655 8949 Facsimile: (03) 9655 8929 International: + 61 3 9655 8929 Internet: www.doi.vic.gov.au/publictransportsafety Postal address PO Box 2797Y, Melbourne Victoria Australia 3000
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