RAIL SAFETY

Rail Safety News is a tri-annual newsletter for accredited rail operators in . ISSUE 6 OCTOBER 2011 It serves the purpose of being an important tool for the regulator to communicate rail safety information and initiatives that will help drive change. Chris McKeown Director Rail Safety

On 19 August 2011, the Council of Australian (COAG) signed Inter-Governmental Agreements to establish national safety regulatory scheme frameworks in the rail and commercial maritime sectors. Both frameworks are scheduled to come into effect in 2013.

The rail safety regulatory framework includes the introduction of national rail safety administered by a new national regulator based in .

This process is being led by the National Rail Safety Regulator Project Office who worked with the states and territories, and to develop the scope and detailed arrangements for implementation of these significant national reforms. The agreement represents a major milestone in this process.

At this stage, Transport Safety Victoria (TSV) understands that day-to-day regulatory functions will continue to be performed locally under delegation from the national regulator. In addition, TSV will continue to be directly responsible for rail safety in regard to light rail.

TSV and the Department of Transport have worked collaboratively throughout the negotiations to seek to ensure the capacity to respond quickly to changes in local risk factors in Victoria, which is integral to the design of the new regulatory system.

The inter-governmental agreement also includes arrangements for cooperative resource sharing between the Office of the Chief Investigator in Victoria and the Australian Transport Safety Bureau as the national investigator.

TSV is committed to ensuring a smooth transition to the implementation of the new national regulator, and that safety remains the top priority for rail safety regulation in this State.

2 Rail safety – perception and reality 21st International Railway Safety Conference 16 – 21 October 2011

TSV is delighted that plays host to this year’s International Railway Safety Conference (IRSC). For many of Victoria’s rail safety professionals, the opportunity to have this international event on their doorstep and to share industry knowledge and experiences in a global forum is rare and one not to be missed.

‘Rail Safety – perception and reality’ is an enigmatic theme which will be thoroughly explored by participants. TSV is presenting the State’s regulatory roll and showcasing how our risk-based approach to regulation seeks to be best practice.

Alan Osborne, TSV’s Safety Director, is joining Brian Nye (CEO, Australasian Railway Association) and the Hon Terry Mulder MP (Minister for ) in opening the conference program.

If you are attending the conference, look out for TSV’s Manager, Human Factors, Elizabeth Grey, who is presenting on the second day with her paper that explores the value, benefits and implications of a just culture approach for rail organisations and regulators.

Also check out TSV’s poster paper which is on display, about our commitment to excellence in rail safety regulation. This paper contains reflections on TSV’s experience as one of the rail safety regulator’s with the longest experience in of independently administering modern ‘stand-alone’ rail safety .

Of course, please visit the TSV stand, pick up a wide range of rail safety material and chat with our staff. We are happy to answer any questions that you may have! > 3 Exploring a just culture approach

A topic of exploration within TSV has been the value, benefits and implications of the ‘just culture’ approach both across the rail industry and within the regulator itself. The just culture concept is widely accepted within modern safety science and is often promoted to safety critical organisations as a means of enhancing organisational learning by improving reporting about incidents and accidents.

As part of the activities at this year’s International Rail Safety Conference (IRSC), TSV is presenting a paper that explores the literature and offers some observations from the regulator’s perspective on why and how a regulator might adopt a just culture approach. The impact of adopting a just culture approach within industry, the barriers that may prevent effective adoption by the regulator, as well as the benefits and challenges of such an approach will also be discussed. >

4 > Modern thinking those ‘upstream’ involved in all aspects about regulation of the rail system such as procurement, design, operations, management and Modern rail safety regulation aims to maintenance. promote continuous improvement in the This legislation was implemented management of rail safety. Achieving following serious accidents in New this outcome relies on good regulatory South Wales at Glenbrook, in 19991 and decision-making driven by legislation Waterfall in 20032, and in Victoria (for and based on prevailing societal example, Broadmeadows in 20033). values. These decisions should be guided It reflects rising public concern as noted by regulatory good practice, supported by Justice McInerney in the report on by findings from safety science research. the Glenbrook accident, following these events and others in the UK. It also an opportunity brings our rail safety legislation in line for learning and with the changes to safety regulation that have occurred internationally during organisational the last 30 years.

improvement. TSV’s regulatory approach4,5 fits broadly within this graduated intervention The rail safety legislation in Victoria has, model. In this model, enforcement since 2006, provided the regulator with begins with cooperative strategies a modern framework that allows for (education and influencing), which are more graduated regulatory interventions located at the base of the ‘enforcement and a greater focus on pyramid’. Interventions then progress and safety management systems. This through administrative tools such as legislation enhances the regulator’s improvement notices and prohibitions scope to facilitate safety improvement to more punitive strategies (such as through a range of regulatory prosecution, suspension and revocation mechanisms, including the introduction of accreditation) if the earlier strategies of a chain of responsibility where all fail4. Improvement notices sit around the stakeholders have safety duties including middle of the pyramid. >

5 > Modern thinking about safety and education through to administrative are acts or omissions in which a person sanctions and prosecution) to achieve knows or can be reasonably expected The just culture approach seeks to improved system safety may be enhanced to foresee the outcome, but proceeds balance the need to hold people by the incorporation of a just culture despite this knowledge8. In a just culture accountable for their actions while perspective. approach, reckless and malicious acts facilitating opportunities to learn require sanctions and/or punishment10. from accidents. It is ‘just’ in that Determining punishment is reserved for willful Evidence for just culture violations and destructive acts. Actions A prerequisite for a just culture is arising from human error are seen that all members of an organisation The just culture approach is the product as an opportunity for learning and understand where the line is drawn of modern thinking on the causes of organisational improvement. The success between unacceptable behaviour that accidents in complex socio-technical of this approach depends on a mature deserves disciplinary action and the systems and is increasingly supported by understanding of the causes of human remainder where punishment is neither evidence from research in a number of error. Error is considered a symptom appropriate nor helpful in furthering the safety critical industries7,11. It has been of wider organisational or systemic cause of safety6. Marx7 has addressed applied in industries such as aviation deficiencies and the inevitable outcome this issue, distinguishing three classes and healthcare and has been the subject of human activity. People who ‘make’ of behaviour: human error, at risk of enquiry in the fields of human factors errors often inherit error-provocative behaviour and reckless behaviour and and sociology. Parallels to the just culture situations. malicious or willful violations. Human approach may be drawn in regulatory error occurs when an intended action and legal theory particularly responsive fails to achieve an intended outcome, regulation12,13 and from guidance such as punishment is and inadvertently causes an unintended the model litigant guidelines14. Further result. Sometimes these errors occur support for a just culture approach neither appropriate simply because the systems or conditions may be inferred from some regulatory nor helpful in that people work within fail them8. The commentators. For example, it has been just culture response is one of consoling, suggested that deterrence activities furthering the cause educating and improving design of such as prosecution, if not undertaken of safety systems9. At risk behaviour tends to thoughtfully, could lead to situations involve violations (or rule breaking) that where regulated organisations become creates a risk to safety, resulting in an uncooperative and defensive15,16. unintended outcome8. The behaviour Thus sharing of critical information Contrary to some misconceptions, the may feature short cuts and poor habits in is restricted and the safety outcome just culture approach is not a free pass order to get the job done. The individual reduced. Hence just and fair intervention for poor behaviour. Implemented well, involved may not expect that there is a by a regulator could be a key feature in it can provide a framework for decision- risk to safety10 as such behaviour may promoting safety. making about the need for and extent well be the norm within the workforce of punishment. It takes into account and the organisation. The just culture the systemic causes of accidents based Why deterrence is not enough response to at risk behaviour involves on research on human behaviour and coaching, incentives, and disincentives. complex socio-technical systems. A The traditional view of regulation and Malicious willful acts intend to cause proposition is made that the regulator’s justice is punishment of the guilty through harm. Reckless behaviour is action taken ability to employ the full spectrum of prosecution. Prosecution is based on the with conscious disregard for safety. These the regulatory toolkit (from influencing rationale that safety can be maintained

6 by punishing the guilty parties, apparently designers, managers and maintenance research has shown that decisions may acting as a deterrent to future behaviour staff. These failures are considered latent not always be made in a rational and that might lead to accidents. While because the causes of the failure can lie logical fashion and may be subject to prosecution should be available as an undetected and dormant for considerable a range of cognitive biases, which lead intervention, the punitive-deterrent periods until they combine with other to poor decision-making18. Decision- strategy seems rigid when considered factors causing an accident situation that making involves complex psychological from a just culture perspective. A more reveals them9. In a just culture, incidents mechanisms. For example, research has sophisticated approach is required to are recognised as manifestations of shown that experts do not systematically improve safety in complex socio-technical earlier systems deficiencies and should compare options to select the best one, systems. Such an approach needs to be treated accordingly. Incidents are a but use schemas developed from past reflect the findings from safety science, valuable source of insight required for experience to efficiently choose an and social, behavioural and regulatory continual improvement, but only if they option that is known to work in similar research. The issues are worthy of are seen as opportunities for learning. situations19. consideration. Punishment as a deterrent Benefits of just culture: Learning Human error and for intentional behaviour from incidents and accidents organisational failures There are two ways that punishment can Leape, before a hearing of the US Research in psychology8 suggests that deter future acts. The first is the idea Congress, asked how could the “… people are fallible as a result of innate of specific deterrence. That is, having report gathering function of regulators limitations which are determined by experienced negative consequences, be modified to become a force for error our biology, for example, our evolved the prosecuted entity (be it a person reduction rather than an incentive for cognitive abilities (such as selective or company) is less likely to perform error concealment”(20,p.97). In seeking to attention), and the impact of distraction the behaviour again through fear of build on existing safety improvements, and fatigue under contemporary experiencing those consequences again. the US rail regulator, the Federal Railways industrial workloads. Threatening people The second is the concept of general Administration (FRA)21, acknowledged with punishment will not stop them deterrence. That is, by becoming aware that it did not know enough about how forgetting a crucial item under pressure. of negative consequences imposed on and why accidents occurred. The FRA Nor will it prevent errors that arise due to someone else, other non-prosecuted identified that the Federal Employee poor systems design (such as design that entities are less likely to engage in that Liability Act (FELA), a law passed by does not match how people perceive and behaviour through fear that they will Congress in 1908 to enable railroad process information, build models of the receive these consequences. employees the right to recover damages world, or how decisions are made under for any injury that results from the pressure). There is mixed evidence for the carrier’s negligence, was a barrier to effectiveness of punishment in deterring organisational learning and safety Research on accidents in complex future offences. The evidence is improvement. socio-technical systems has identified particularly weak for general deterrence. contributing factors from the General deterrence is based on rational A punitive environment has also been organisational and management choice theory, which views individuals found to be a barrier to learning by system9. These latent failures are usually and companies as ‘utility maximisers’ studies in the healthcare industry. associated with system failures removed who logically weigh up the costs and Research1 focused on blood transfusion in time and/or space from the operational benefits of compliance and make a safety found that the effectiveness locus of the organisation and originated decision based on maximising benefits of data collection and analysis of unintentionally by people such as and minimising costs17. However, transfusion errors, adverse events, > > 7 > and near misses, depended on the Following the implementation of a upon the regulator’s ability to be flexible willingness of individuals to report this mandatory reporting system in Denmark, in its application of its legislation. information. Errors were widely perceived Naviair, the Danish Air Traffic Control with a requirement for as a reflection of personal negligence, service provider employing all air traffic punitive action against regulatees or indeed, medical negligence was defined controllers in Denmark, decided to conversely, limited legislative basis for as the “failure to meet the standard actively implement this new reporting punitive action are likely to have trouble of practice of an average qualified system. This decision was not made adopting the approach successfully. The practicing physician in the speciality solely because it was mandatory, but enforcement pyramid with its graduated in question”(22,p.383). As a result, only a because management foresaw a benefit intervention approach adopted in minority of medical errors tended to for the company’s main product, flight Victoria, allows the regulator to make be reported, typically those errors that safety27. During the first 24 hours of decisions about how to intervene. cannot be covered up23. Further, because operation, Naviair received 20 reports The just culture approach adds another a punitive inquiry tends not to go beyond from air traffic controllers. One year after dimension to this decision-making identifying culpable people, there was the reporting system was implemented, that is supported by growing research an unwillingness to understand the Naviair had received 980 reports evidence and meets a commonly held whole system, and therefore the benefits compared to the previous year’s 15 desire for fair and just intervention that of improved system design were not reports28. promotes trust. realised. Given our understanding of system The implementation of just culture Conclusion safety developed during the last 40 initiatives in the aviation industry has years, there is a moral and pragmatic been found to significantly increase There is preliminary evidence for benefits imperative to deliver the safest systems reporting of incidents, particularly of ‘low to the regulator’s goal of improved by taking account of human fallibility risk’ events and near misses24,25. Baines26 system safety through increased and the imperfection of systems. While attributed increased reporting to: reporting by adopting a just culture more research is required, the just approach. The literature does not yet culture approach has the potential to • a belief that the just culture principles reveal whether the adoption of a just provide sound criteria for making these would be followed and that punitive culture approach by the regulator leads decisions in structured and systematic action would be considered within the to similar adoption in industry or what ways. The just culture approach is not a just culture other benefits may accrue through free pass for poor behaviour. Therefore, broader application of the approach. specific criteria for determining when to • a better understanding of reporting However, these findings encourage requirements though training intervene need to be well documented further exploration of the potential and communicated clearly; so that the • more effective investigations and benefits of the approach. There is an parameters of acceptable behaviour are dissemination of findings opportunity here for leadership in known and understood by all parties. ensuring that performance management As this discussion continues within TSV, • a belief that reporting will make a systems whether in regulators or a next step will be to draft criteria for difference in improving safety. rail operators are designed to drive assessing organisational behaviour and optimal behaviour. test them internally against a range of Within a regulator’s office, the success case studies. of a just culture approach would depend

8 This is a journey the regulator and the 4. Transport Safety Victoria. Draft TSV regulatory National Research Centre for OHS Regulation, industry should consider in order to approach. Victoria , Melbourne, 2011. Working Paper 75; 2010. [date accessed Aug 22nd 2011]. Available from: 18. Kahneman D, Frederick S. “Representativeness achieve improved safety outcomes. In www.transportsafety.vic.gov.au/ _data/assets/ Revisited: Attribute Substitution in Intuitive adopting such an approach regulators pdf_file/ 0008/38861/Transport-Safety-Victoria- Judgment”. In Gilovich T. Griffin D. Kahneman regulatory-approach-policy-2.pdf need to seek mature relationships D. (eds). Heuristics and Biases: The Psychology 5. Fung A. Solass I. Baxter K. Transport Safety of Intuitive Judgment. Cambridge, Cambridge with regulatees, and demonstrate Victoria: A commitment to excellence in rail safety University Press. p.51–52; 2002. organisational commitment through regulation. Unpublished poster paper, presented 19. Klein, GA. Sources of power: How people make at the International Rail Safety Conference, decisions. Massachusetts: MIT Press; 1998. educated, skilled and committed Melbourne; October 2011. regulatory staff. Likewise, regulated 20. Leape, LL. Testimony, United States Congress, 6. Hudson PH, Vuijk M. Meeting expectations: A new Subcommittee on health of the committee on organisations aiming to benefit from the model for a just and fair culture. Paper presented veterans’ affairs, House of Representatives. One just culture approach need equally skilled at the SPE International Conference on Health, Hundred Fifth Congress, First Session. Serial No. safety and environment in oil and gas exploration 105-23. October; 1997. employees and also to seek mature and production, Nice, France (SPE 111977); 2008. 21. Federal Railways Administration. The FRA risk relationships with the regulator founded 7. Marx D. Patient Safety and the “Just Culture”: A reduction program: A new approach for managing on mutual respect and an understanding primer for health care executives; [Internet] 2001. railroad Safety. FRA, Washington, DC [Internet]. [date accessed 14 Jul 2011]. Available from: www. of the role of the regulator as a defence December 2008. [date accessed 22 August 2011]. mers-tm.org Available from: www.fra.dot.gov/downloads/ in depth. Both rail safety regulators 8. Reason J. Human error. New York: Cambridge safety/A NewApproachforManagingRRSafety.pdf and the rail industry in Australia should University Press; 1990. 22. Leape LL, Brennan TA, Laird N, Lawthers AG, explore further the principles of just 9. Reason J. Managing the risks of organisational Localio R, Barnes BA, Hebert L, Newhouse JP, culture and its potential application. accidents. Ashgate, Surrey United Kingdom, 1997. Weiler PC, Hiatt H. The nature of adverse events 10. Marx D. Whack –a-Mole. By Your Side in hospitalized patients. The New England Journal As we move towards the implementation Studios; 2009. of Medicine. 1991; 324(6): 377-384. of the National Rail Regulator in Australia 11. Dekker S. Just culture: Balancing safety 23. von Thaden TL. Hoppes M. Measuring a just with modern legislation, how just culture and accountability. Ashgate Publishing, culture on healthcare professionals: Initial survey Burlington; 2007. results. Paper presented at the Safety Across is positioned as a part of the regulatory High-consequence Industries Conference, St. 12. Ayres I. Braithwaite J. Responsive regulation: Louis, MO; 2005. approach will be increasingly important. Transcending the deregulation debate. Oxford University Press, New York, 1992. 24. Baines K. Just culture: From aspiration to ¼¼ For the complete conference paper reality. Baines Simmons Limited, [Internet] 13. Braithwaite J. Restorative justice and responsive 2008. [date accessed: 25 July 2011]. Available please contact TSV or go to the IRSC regulation. Oxford University Press, New from: www.raes-hfg.com/reports/21may09- website at www.irsc2011.org/ York; 2002. Potential/21may09-baines.pdf 14. Department of Justice, Alternative Dispute 25. Eurocontrol. Eurocontrol voluntary ATM incident Resolution Directorate. Victorian model reporting. EVAIR Safety Bulletin; 1, 3-19. 2008. litigant guidelines. Department of Justice, References State of Victoria. Melbourne. [Internet]. March 26. National Reporting and Learning Service. NRLS 2011. [date accessed: 19 Jul 2011] Available quarterly data workbook up to March 2011. NPSA. 1. McInerney PA. Special Commission of Inquiry into from: www.justice.vic.gov.au/wps/wcm/ London. [Internet] August 2011. [date accessed the Glenbrook Rail Accident Final Report; April connect/justlib/DOJ+Internet/resources/ 3 16 Aug 2011]. Available from: www.nrls.npsa. 2001. Available from: www.pandora.nla.gov.au/ /4/34fd7f00459fb2b0b6a2b6e6d4b02f11/ nhs.uk/resources/ collections/quarterly-data- tep/47325 RevisedModelLitigantGuidelines.pdf summaries/?entryid45=131140 2. McInerney PA. Final report of the special 15. Gunningham N. Sinclair, D. Multiple OHS 27. Høivik D. HSE and Culture in the Petroleum commission of inquiry into the Waterfall rail inspection tools” Balancing deterrence and Industry in Norway. Paper presented at the SPE accident. Volume 1. : Special compliance in the mining sector. National International Conference on health, safety and Commission of Inquiry into the Waterfall Rail Research Centre for OHS Regulation, Canberra. environment in oil and gas exploration and Accident; 2005. Working Paper 55; 2007. production, Rio de Janeiro, Brazil; 2010. 3. Australian Transport Safety Bureau. Runaway 16. Gunningham N. Sinclair D. Regulation and the 28. Nørbjerg PM. The creation of an aviation of suburban electric passenger train 5264 and role of trust: Reflections from the mining industry. safety reporting culture in danish air traffic collision with diesel locomotive hauled passenger National Research Centre for OHS Regulation, control. Kastrup, Denmark, Naviair Publication; train 8141. Rail investigation report no. 2003/0001. Canberra. Working Paper 59; 2008. November 2003. Australian Transport Safety Bureau, Civic Square 17. McCallum N, Schofield T, Reeve B. Reflections ACT. 2003. on general deterrence and OHS prosecutions.

9 TSV’s IRSC 2011 Poster Paper ‘Transport Safety Victoria – a commitment to excellence in rail safety regulation’ By Andrea Fung, Ida Solaas and Kirsty Baxter, TSV

As part of enriching the regulatory > Towards a ‘risk-based’ approach perspective on rail safety at the IRSC, The first major change in TSV’s journey TSV is also contributing a poster paper. was from annual high-level audits of all It contains reflections on our experience as accredited parties to a targeted risk- based auditing and inspection program. one of Australia’s rail safety regulators with The previous audits were ‘broad-brush’ the longest experience of independently and verified that high-level processes administering modern ‘stand-alone’ were in place against the relevant standard. This changed significantly rail safety legislation. when modern legislation was introduced as TSV began to collect risk and industry The paper (‘Transport Safety Victoria- a commitment to intelligence. Our audits now identify excellence in rail safety regulation’) begins with background specific safety topics of concern in on TSV as Victoria’s independent integrated transport safety relation to each regulated party which regulator committed to excellence in regulation under a modern are prioritised in a quarterly compliance legislative framework. This framework focuses on continuous program. Over time, operators that safety improvements through performance standards and developed greater safety maturity and process requirements for better hazard identification and risk ‘self-regulation’ through robust internal management. Victoria is also one of a number of jurisdictions audit and risk management systems in Australia and overseas to have regulation dedicated solely to have benefited from less interventionist rail safety administered by an independent safety regulator. regulatory tools and style from TSV. The paper reflects TSV’s experience with administering modern legislation, and finds the gap between the promise and the actual performance of ‘modern’ regulatory systems needs to be more carefully considered. Indeed, while TSV has made significant progress, the journey continues to be challenging in some specific areas. >

10 Towards being ‘outcomes-based’ Challenges of enforcing Challenge of performance performance-based legislation measurement Another major step was the considerable effort expended to develop the internal There is now abundant literature The current push in Victoria is to lift the and industry expertise to effectively on the potential drawbacks of performance of regulators by measuring achieve compliance with performance performance-based legislation, including outcomes, not just outputs. However, and process-based legislation. This inconsistencies in interpretation, a attempts to measure outcomes in requires the regulator to undergo decrease in certainty and predictability any meaningful way are fraught with the necessary cultural change in its and significant expertise required. difficulties, including the limitations regulatory approach, as well as be Performance-based legislation also of data and proving causality. For TSV, flexible and take a differential approach requires awareness of the tension regulatory performance is routinely to managing the varying regulatory between providing adequate guidance to assessed internally by verifying that the capacities across Victoria’s different help operators understand requirements desired outcomes were achieved for rail sectors. while allowing them enough flexibility to each safety ‘topic’ identified. In terms choose their own ways to comply. of rail safety outcomes more generally, Challenges of ‘co-regulation’ it is still too early to assess whether the change in regulatory system is causing a Besides being highly dependant on …develop the direct improvement in safety outcomes. the regulated parties’ capacity to self- Nevertheless TSV continues to seek to regulate, the challenge of co-regulation internal and build on its expertise in risk management lies in achieving the appropriate balance and prevention and believes it has made in ‘sharing the regulatory task’ between industry expertise meaningful progress towards focussing the regulator and regulated parties. to effectively achieve on and measuring outcomes. Some argue that regulators need to ‘pay compliance with Such experiences highlight the more attention to the ‘enforced’ part of challenges for regulatory in enforced self-regulation. Co-regulation is performance and administering modern legislation. The also made more challenging by different challenge for the proposed new national understandings of ‘co-regulation’ across process-based rail safety regulator will be to ensure that government and industry stakeholders. legislation. Victoria’s learnings are captured in the new regulatory system while continuing to address the sorts of challenges outlined in the paper to promote rail safety in the future.

¼¼ For copy of the full paper, please visit the TSV website, or contact Andrea Fung at [email protected]

11 Fatigue > management in rail operations

Fatigue is a hazard within the rail industry that needs to be managed. Fatigue can lead to uncontrollable sleep onset and impair performance. Given that the safety of systems often depends on human performance, such impairment can lead to potentially catastrophic incidents such as collisions and derailments. This view is supported by evidence from a review of rail of accidents being conducted in the United States by a regulator-industry working party. The Collision Avoidance Working Group (CAWG) examined 65 main-track train collisions (which occurred between 1997 and 2002) in which human factors causes contributed to train accidents. They found that fatigue (or impaired awareness) contributed to 30 percent of the accidents studied.

Australian rail safety legislation imposes obligations on accredited rail operators to manage fatigue so far as is reasonably practicable (SFAIRP). This obligation connotes an expectation that accredited operators understand the impact of fatigue on rail safety workers and the controls available to minimise or prevent its impact. However, fatigue remains one of the more complex and challenging risk factors to control.

On August 4, 2011, Transport Safety Victoria hosted a seminar on ‘Fatigue Management in Rail Operations’. This was attended by a diverse range of members of the Victorian rail and transport industry, including safety specialists and managers, operations personnel, health professionals, union representatives, consultants, and researchers. The three expert presenters discussed fatigue risk management from three different perspectives: that is, as an expert in fatigue science, a specialist working for a rail safety regulator and a specialist working for a rail operator.

Dr Paula Mitchell, a senior consultant at Integrated Safety Support, described the science of fatigue. Paula spoke about fatigue as a state of impairment that can trigger undesirable safety outcomes and highlighted the causes, symptoms, and consequences of fatigue in an operational setting. This presentation discussed a shift towards more comprehensive risk management approaches to fatigue management, rather than traditional strategies focused on limitation through prescriptive hours of work and rest. At the individual level, Paula warned against the dangers of self-assessing one’s own fatigue. People tend to be unreliable when assessing their own level of fatigue because fatigue impairs this assessment ability. Therefore, by the time a person realises that they are fatigued, chances are that they have been in this state for some time. >

12 > Jenny Alcock, fatigue risk management potential (often underestimated) costs challenge was trying to balance a need specialist at the Independent Transport of fatigue to organisations and industry for enhanced fatigue management with Safety Regulator (ITSR) in NSW, as well as the importance of creating a the competing goals of maintaining presented on the importance of a risk business case for fatigue management. performance and cost efficiency. While management approach to managing her presentation focused on fatigue fatigue in rail operations. Drawing on Human Factors Consultant, Fiona Kenvyn management from the perspective of her experience in dealing with a variety presented a case study based on her frontline employees, it also highlighted a of rail operators, Jenny discussed the experiences in implementing a Fatigue number of broader issues that can affect basic steps required to demonstrate a Risk Management Program (FRMP) at the effectiveness of an FRMP including risk management approach to fatigue. Network Rail in the UK. Fiona discussed the role of organisational and industry- Using rail accident data, she identified the challenges inherent in integrating wide culture, norms, standards and practical tools to help investigate the modern fatigue management practices expectations. potential contribution of fatigue in into the day to day running of a rail incidents. Jenny also referred to the organisation. She noted that the biggest

In summary, the presentations • aims to understand the specific risks; The seminar was highly successful and highlighted that there is no ‘one-size- a follow up seminar is planned for 2012. fits-all’ solution to fatigue management • includes a suite of controls and Copies of the presentations are available in rail operations. Indeed, the expert treatments appropriate for on the TSV website www.transportsafety. presenters stressed the need for a these risks; vic.gov.au/events modern risk management approach to • has ongoing monitoring of fatigue Ref: Collision Analysis Working Group fatigue management that: levels and fatigue-related issues; (CAWG). 65 Main-Track Train Collisions, 1997 through 2002: Review, Analysis, Findings, • makes use of scientifically-based and Recommendations. August 2006 CAWG evidence and guidance; Final Report. Federal Railroad Administration: Washington DC. Accessed 20 September 2011. • continually improves the knowledge Available from www.fra.dot.gov/Downloads/ and awareness of individuals; and test/CAWG_complete_Aug_2006.pdf

• is tailored to the level of fatigue risk maturity of the organisation.

13 By the seat of their pants: cues and feedback used by train crew Submitted by: Nic Doncaster

Nic Doncaster works for the Office of the Rail Safety Regulator (ORSR), in the Department for Transport, Energy and Infrastructure. As a part of his Master’s degree, Nic researched the use of cues and feedback by freight train crews. A review of the literature identified little in relation to the cues (a feature of system, state or environment to which a response is required (Wiggins, 2006)) and feedback (information about what has actually happened (Norman, 1988)) used by freight train crews. Most of what was found focussed on suburban and inter-urban passenger operations, particularly in the UK.

In this South Australian research, eight drivers were interviewed. The interviews were not structured, as the intent was to engage the drivers and encourage them to talk openly. A quote from a paper written by Branton (1978) was used to “set the scene”. The participants were asked to comment on the quote and its relevance to their driving. This information was then explored with the driver.

The drivers noted that they generally started to plan for their trip before leaving for work. They report that they knew the type of train that they would be working, which allowed them to run through scenarios in relation to how the train may handle. These scenarios used knowledge that had developed over the years. When operating trains, drivers noted that they were planning up to several sections ahead, “setting up” the train for expected operational needs, and running through alternate scenarios, whilst also monitoring train performance via various feedbacks provided by the train (generally kinaesthetic). Operational information, including radio communications, was used to further refine driving strategies.

Kinaesthetic sensation, made up of the push (buff) and pull (draft) of the train as it “ran in” or “ran out”, the movement of the loco body, as well as how the train responds to commands, was generally described as the “feel”. The drivers consistently identified that much of the movement was felt “by the seat of their pants”, particularly high run-in forces which resulted in a “kick up the arse”! >

14 > The drivers also reported that while As cues generally develop as a result feedbacks such as displays, exhaust of experience (Wiggins & Glass, 2006), output and sound may be used, these and may therefore be unique to the were not generally used as a primary individual, identifying and coding them source of information. Some drivers may be difficult. However, lineside reported that displays are used to features were consistently identified. validate what they already knew of the state of the train, rather than a primary The project identified a number of other source of information. A key form of issues for further research, including feedback noted was the verbal and non- how crew develop route knowledge, how verbal feedback of co-drivers. they apply it over significant distances of railway, factors associated with relay The drivers consistently described working and driver only operations. difficult sections of corridor, while most Branton, P. (1978). The Train Driver. In W. noted that, when travelling in a crew Singleton (Ed.), The Analysis of Practical Skills. car, they would wake and, through Baltimore: University Park Press. the movement of the train, be able to Klein, G. (2003). The Power of Intuition: How to determine within a very short timeframe, use your gut feelings to make better decisions where they were on the network. This, at work (First ed.). New York: Currency along with the other findings, suggest Doubleday. that train crew work from detailed Norman, D. (1988). The Design of Everyday mental models of the network, and of Things. New York: DoubleDay. train performance, to such a degree that Wiggins, M. (2006). Cue-based Processing and the behaviour has become ”intuitive” Human Performance. In W. Karwowski (Ed.), (Klein, 2003). Encyclopedia of Ergonomics and Human Factors (2nd ed., pp. 641-645). London: Taylor and By identifying and understanding the Francis. feedback used by train crew, a more Wiggins, M., & Glass, R. (2006). The use of focused approach to the design of cues in the interpretation of weather radar elements of the railway system may returns amongst pilots. Paper presented at the ESS2006: Evolving Systems Safety – The be possible, including enhancement 7th International Symposium of the Australian of lineside signage, improvements Aviation Psychology Association. Retrieved to enhance audible and kinaesthetic 11 May 2008, from www.aavpa.org/seminars/ feedbacks, or other displays to support ess2006/pdf/pdf%20papers/Wiggins%20&%20 these feedbacks. Understanding Glass.pdf feedbacks used may also assist in refining training systems, for example simulators, to enhance their fidelity.

15 Rail Incidents Review

The following is a summary of the Common themes in these reports include: investigations reports into rail safety • the importance of controls to prevent train runaways incidents that have occurred in Victoria, (Norway, Sweden, UK) NSW, New Zealand, Europe, Canada, and • the importance of inspection of road over rail bridge the USA over recent months. parapets (UK and France) • risks associated with train drivers using mobile phones while driving (USA, Canada)

• large vehicles at level crossings and their ability to site trains (Finland, Estonia, Canada).

There are also investigations into a passenger caught in train doors (Austria), and a train over-speeding when taking a diverging route owing to misreading signals (Poland). These are of specific interest to Victoria, having been the precursors to fatal incidents.

16 Office of the Chief The Office of Transport Investigator (VIC) Investigation, NSW www.transport.vic.gov.au/about-us/oci/ www.otsi.nsw.gov.au safety-investigations#Rail%20incidents

Comeng train fire, took the route set for the turn into Derailment at points 133D, collision, Croxton Railway Station Abbotsford Street and was struck South Dynon Junction Wee Waa, by an oncoming crossing Occurrence date 17 March 2010 the intersection from the opposite Occurrence date 20 Oct 2010 Occurrence date 1 Sep 2010 Investigation release date 13 Nov 2011 direction. The incident resulted from Investigation release date 3 Aug 2011 Investigation release date 2011 A (MTM) the incorrect action of the driver A shunt movement that required Two locomotives Comeng train was departing the of the transport tram in changing access to the main line was being struck a road motor vehicle (RMV) Croxton Railway Station when the the setting of the points. There was conducted from the Melbourne on a private level crossing located driver observed sparks and flames significant damage to both Freight Terminal. When the shunt in the Narrabri West to Wee Waa emanating from the undercarriage of although no reported injuries to move was setting back from the section. The driver of the RMV the last motor car of the train. The passengers or tram drivers. main line into the terminal two suffered fatal injuries. No crew fire was subsequently extinguished wagons in the middle of the rake members of D551 were injured but by the Metropolitan Fire Brigade. Tram-to-tram collision, derailed at points on the main line. they were treated for shock. None of the occupants were injured At that time, the South Improvement , intersection of The level crossing is designated in the incident, though damage Alliance was engaged in by the Australian Rail Track was sustained to undercarriage Kings Way and Sturt Street, commissioning signalling and track as a “private equipment and the train’s exterior. South Melbourne infrastructure upgrades at this area accommodation crossing”. It is The overhead contact wire parted of operation on the Australian Rail Occurrence date 12 January 2011 part of a private road system that due to overheating. Track Corporation network. During Investigation release date 3 Aug 2011 provides the property owner with the work it was necessary to render The investigation found that there access from the main portion of the Two trams on route 55 along Kings the signalling system inoperative had been a flash-over of a traction property to paddocks and farming Way (one outbound, one city-bound) and to manage rail traffic utilising motor and that the contacts of one infrastructure. approached each other at the Sturt a subsystem of administrative line breaker created a sustained Street intersection. A previous procedures. The investigation found The investigation determined that arc between its contacts and the tram movement on the citybound that points were incorrectly set for the primary cause of the collision casing. The intense heat generated track had been a diverted St Kilda the shunt movement and that the was the driver of the RMV not from this arc melted the steel casing Road service. In accordance with senior signaller did not adhere to the stopping and giving way to the and ignited the fibreglass insulation normal operating procedure, this South Improvement Alliance work approaching train. There were material causing the fire. left the manually-operated points instructions when setting the route. no obvious factors which would The investigation found that set for the turn from Kings Way into The investigation also found that have prevented the driver of the a substation’s circuit breaker Sturt Street, requiring the driver Skilled Rail Services did not employ RMV from seeing or hearing the settings were incorrectly adjusted of any following Route 55 tram to a formal or robust process in the approaching train. Although not and as a result the train was not manually restore their setting. In appointment of senior signallers for a contributing or causal factor, protected against over-current. this case, the next tram on the city- the commissioning works. the windscreens on the train were This allowed the continuation of bound track was a route 55 service. scratched and dirty and provided less The investigation recommended a an excessive current flow resulting This tram stopped at the than optimal visibility. review of the practice of permitting in the overheating and parting of immediately prior to the intersection. the access of normal revenue the overhead contact wire. The When the traffic lights changed to services to the network during investigation concluded that the ‘proceed’, the tram moved ahead infrastructure commissionings train’s electrical components and the with the driver responding to a that require the signalling system substation circuit breaker were not ‘straight-ahead’ tram priority arrow to be rendered inoperative. The maintained to a satisfactory standard and turned unexpectedly into the investigation also recommended and this led to the mechanical side of the opposing route 55 tram that South Improvement Alliance and electrical failure of these that was passing on the adjacent and Skilled Rail Services review components. track. the roles, responsibilities and The leading bogies of both trams training of signalling staff for Tram-to-tram collision, Yarra derailed and both vehicles sustained commissioning works. Trams, intersection of Flemington significant exterior damage. Consequent reports recommended Rd and Abbotsford St, North that some form of interlocking of Melbourne tram and traffic signals with track Occurrence date 3 Sept 2010 points control should be considered Investigation release date 13 Jul 2011 by Yarra Trams.

An out-of-service tram was travelling along Flemington Road toward the city. At the intersection with Abbotsford Street the driver mistakenly altered the setting of the points ahead. When the traffic lights permitted him to proceed across the intersection, his tram > 17 Australian Transport New Zealand U.K. – Rail Accident Safety Bureau www.taic.org.nz Investigation Bureau www.atsb.gov.au www.raib.gov.uk/publications/ investigation_reports/reports_2011.cfm

Derailment of freight train Signal passed at danger Report 08-111: Express freight Uncontrolled freight train 2224 at Exeter, NSW on at Yerong Creek, NSW Train 524, derailment, near run-back between Shap 24 January 2010 Puketutu, North Island Main and Tebay, Cumbria Occurrence date 25 February 2011 Trunk, 3 October 2008 Occurrence date 24 Jan 2010 Investigation release date 19 May 2011 Occurrence date 17 Aug 2010 Investigation release date 4 Jun 2011 Investigation release date 15 Aug 2011 A southbound Brisbane to Occurrence date 3 Oct 2008 Investigation release date 4 Aug 2011 A loaded freight train travelling Melbourne freight train passed the This report makes recommendations from Medway Junction to Berrima home signal at Yerong Creek at red The second-to-last wagon on an concerning the management of Junction, derailed one bogie on the (stop) without authority. There were express freight train conveying two fatigue and improving rail industry second-last wagon at Exeter, NSW. no injuries or damage as a result of loaded liquid petroleum gas tanks, information on fatigue-related It was determined that the wagon of the incident. derailed while travelling around a accidents and incidents. the train derailed due to a ‘screwed 260-metre (m) radius right-hand journal’ as a result of a wheel curve at the posted line speed of bearing failure. Safe working irregularity 60 km/h. The locomotive engineer Collision between an articulated involving a freight train and an tanker and a passenger train at While there was insufficient evidence stopped the train after hearing empty passenger train Manildra, to determine the cause of the bearing an automated voice alert from Sewage Works Lane user worked failure, the investigation identified NSW a dragging equipment detector, crossing near Sudbury, Suffolk located about 500 m past the point two safety issues in relation to the Occurrence date 10 February 2010 of derailment. The derailed wagon Occurrence date 17 Aug 2010 in-service condition monitoring of Investigation release date 18 May 2011 Investigation release date 11 Aug 2011 the wheel bearing, and, wagons remained upright and connected regularly operated at speeds up to 15 An empty passenger train WP46 to the train. None of the other A train collided with an articulated km/h higher than the mandated limit was authorised to travel through 27 wagons on the train derailed. road tanker at a user worked for some classes of track. Manildra Yard on the main line. The investigation determined that crossing, causing the train to derail. However, at the same time a freight the cause of the derailment was Four passengers and the train train was already standing on the attributed to a combination of driver were seriously injured. The Safe working irregularity/breach main line, having recently completed the wagon condition and track driver of the road tanker did not at Bomen NSW shunting within the yard. The driver condition. The investigating use the telephone provided before of WP46 heard radio chatter relating body made one new safety driving onto the crossing, although Occurrence date 6 Sep 2010 to the freight train, so he broadcast recommendation in this report it was a requirement to do so. The Investigation release date 7 Jun 2011 that train WP46 was approaching relating to the way with which investigation also found that the temporary speed restrictions are set A safe working irregularity involving and was authorised to travel through long waiting times that road vehicle when multiple track geometry faults a freight train occurred when the Manildra on the main line. The drivers sometimes experienced within a common section of track network controller attempted to crew of the freight train immediately before being given permission to are identified. set the route for the train to depart replied that they were standing on use the crossing led to a high level Bomen Yard and proceed onto the the main line and advised the train of non-compliance with the correct mainline towards Melbourne. The to stop. procedures for its use. Processes network controller was unable to While a number of defences served relating to misuse at user worked change an absolute signal from to avoid a collision in this case, a crossings did not identify this issue a stop (red) aspect to a proceed serious safe working irregularity and procedures for responding to aspect (green), so he gave verbal occurred where one train had been misuse and near miss incidents on authorisation to the driver of the authorised to proceed over track user worked crossings were unclear train to depart Bomen and pass the occupied by a second train. The and sometimes not complied with. signal while it was displaying a stop investigation concluded that the indication. However, issuing a verbal ARTC network controller fulfilled Bridge strike and road authorisation was not in compliance a shunt order without entering with the safe working rules in this information into the computer vehicle incursion onto the case. The network controller should system identifying that both the roof of a passing train have issued a written Special Proceed main line and loop were occupied. near Oxshott Station Authority to authorise the train to The controller had later forgotten Occurrence date 5 Nov 2010 pass the signal at stop. about the track occupancies when Investigation release date 4 Aug 2011 authorising train WP46 to travel through the Manildra Yard. A lorry fell from a road bridge onto the railway and struck the roof of a passing train. The lorry had collided with the bridge’s parapet and partly demolished it. The rear three carriages of the train were damaged and the rear carriage of the train derailed. One passenger, sitting directly beneath the point of impact, was seriously injured and five other passengers received minor injuries. Two recommendations were made concerning issuing guidance for local highway authorities, together with two recommendations concerning local government highway safety inspections and safety measures

18 USA France www.ntsb.gov www-developpement-durable.gouv.fr

at the bridge where the accident on board, and then collided, at Massachusetts Bay Transportation Collision between long distance occurred. One recommendation to between 40 and 50 mph (64 to 80 Authority collision passenger train and agricultural the railway infrastructure manager km/h), with the rear of a stationary trailer on double track line Occurrence date 8 May 2009 was made to enhance existing train. The investigation identified between Limoges and Brives. structural examinations at bridges that the excavator was placed Investigation release date 13 Apr 2011 carrying roads over railways. into an unbraked condition while Westbound Massachusetts Bay Occurrence date 3 July 2009 Investigation release date Jan 2011 being manoeuvred onto the track. Transportation Authority (MBTA) Recommendations were made Green Line train 3612 struck An agricultural trailer loaded Accident at Falls of relating to modifications to the the rear of standing westbound with hay fell on the railway after Cruachan, Argyll design of the excavator, a review MBTA Green Line train 3808 near falling down a cutting. Hit by the of the safety requirements that are Occurrence date 6 June 2010 Government Centre Station in locomotive of the train, the trailer specified for this type of machine, Investigation release date 14 Jun 2011 Boston in an underground tunnel was projected and fell on a passenger and a review of the training of segment. One car from each train car. Two serious injuries resulted. A train struck a boulder that had people who control this type of derailed and 68 injured passengers fallen onto the track. The boulder machine on site. and crew members were transported lifted up the front coach of the to local hospitals. Monetary Derailment of a train two-coach train and derailed it to Runaway of an engineering train damages were estimated to be about following the collapse of a block the left and down an embankment. $9.6 million. The probable cause of a bridge parapet in Choisy-le- The boulder had fallen down the from Highgate of the collision was determined to Roi cutting slope onto the railway from Occurrence date 13 August 2010 be the failure of the pilot operator within the railway boundary. It had Investigation release date 16 Jun 2011 of the striking train to observe and Occurrence date 20 Dec 2009 become insecure due to the growth appropriately respond to the red Investigation release date Mar 2011 of tree roots around it, which An engineering train ran away along signal aspect at 744A because he A motor vehicle struck the parapet gradually prised it from its stable part of the Northern Line of London was engaged in the prohibited use of a road over rail bridge. A large position, and soil erosion from Underground. The train consisted of of a wireless device, specifically stone fell from the parapet onto the normal rainfall. The infrastructure a self-propelled diesel-powered unit text messaging, that distracted him track. The train struck the stone and manager’s earthworks management designed for re-profiling worn rails. from his duties. Contributing to the derailed. 600m track was damaged, system applied to cutting slopes had At the end of grinding operations accident was the lack of a positive 4800m catenary destroyed and the not identified the hazard of loose the crew of the unit found that they train control system that would train damaged. boulders in the area that the accident were unable to restart its engine to have intervened to stop the train and occurred. Recommendations travel away from the site of work. prevent the collision. included improving the clearance of An assisting train, used for passenger vegetation growing on earthworks services on the Northern line, was Derailment of a freight train at so that hazards to the safety of sent to the rescue of the grinding Bully-Grenay station railway operation can be identified, unit. The assisting train was coupled Occurrence date 29 Jul 2010 improvements to the collection of to the grinding unit by means of an Investigation release date 2011 slope data, and improvements to emergency coupling device, and the the process for the implementation braking system of the grinding unit A brake failure on a wagon of remediation works to prevent was de-activated to allow it to be locked the axles resulting in 25 future earthworks failures. A towed. The coupling device fractured cm wheels flats. The concerned recommendation made relating while being towed and the grinding wagon, with all 19 following to the prevention of lighting unit began to run back down the wagons subsequently derailed on diffusers and other saloon panels gradient towards central London. a set of points. Track, signals and on rolling stock becoming displaced The crew of the grinding unit, who catenary were also damaged and during accidents was similar to a had no means of re-applying the services on the line were interrupted recommended safety action from the brake, jumped off the unit as it for five days. The accident investigation into the Craigieburn passed through a station. It then ran was caused by a malfunction train collision in 2010 which unattended for about four miles. of a brake valve, the probable suggested inspection of the Comeng The investigation found that the cause being foreign material fleet to assure the adequacy of emergency coupling broke because it left, understood to be sealant, the fastening of items in overhead was not strong enough for the duties in the unit after maintenance. positions in passenger saloons. it was intended to perform, and had The investigation highlighted poor been inadequately designed and quality management system in procured. Seven recommendations maintenance workshop and made Runaway and collision of a were made, covering the processes recommendations regarding the road-rail vehicle near Raigmore, for introducing new engineering maintenance of brake distributors Inverness equipment, review of existing and the implementation of a equipment, investigation of mandatory system of qualification Occurrence date 20 July 2010 incidents, training of staff, the for those working on safety critical Investigation release date 14 Jul 2011 operation of unbraked vehicles, and equipment. As an operator was placing a road- the quality assurance processes used rail excavator onto the railway the by LUL and its associated companies machine began to run down the gradient. The people who were in attendance were unable to stop the machine before it gathered speed. The machine ran for 1.41 km with the machine operator > 19 Spain Norway Sweden www.aibn.no

Collision with persons crossing Uncontrolled freight system deficiencies resulted in the Wagons rolling uncontrolled on track at Platja de Castelldefels, car movement from operator and infrastructure manager the Östavall – Alby line Barcelona Alnabru to Loenga being unaware that Alnabru had fundamental faults and deficiencies Occurrence date 2 May 2009 Occurrence date 23 Jun 2010 Occurrence date 24 Mar 2010 in terms of operational and technical Investigation release date Jan 2011 Investigation release date 31 Jan 2011 Investigation release date March 2011 safety barriers. When a train arrived at Östavall, the A long distance express train A freight car set consisting of During the uncontrolled movement driver had to move the locomotive knocked down a group of people empty container freight cars rolled it was estimated that the wagons to the other end of the train in order who were crossing the tracks to uncontrolled from Alnabru shunting reached a speed of approximately to propel the wagons to the timber reach the opposite platform instead yard, down to Loenga and into 125 km/h. It was expected that a terminal. After the driver had backed of using the provided underground the sea at Sydhavna in the Port of derailer, combined with the track’s in to the timber terminal in Östavall, passage. As a result 12 people were Oslo. The accident was triggered layout and curvature on part of the he decoupled the wagons and parked killed. No recommendations were by a misunderstanding between route would derail the freight cars them in the terminal. He then drove made by the investigation, though the local traffic controller and the and bring them to a halt. Instead, the locomotive to Ånge. A private examination of controls in place shunter about which shunting route the derailer was sheared off and individual who was in the vicinity of across Europe was made. One such to set, and the result was that the was later found 250–300 metres the railway in Östavall noticed that control is fencing between tracks in freight car set started rolling from an further down the track. During the wagons were rolling and contacted station areas. arrival track at Alnabru. When the uncontrolled movement a two-axled the railway. Just prior to the call, shunter added an extra freight car container wagon derailed, together the remote dispatcher had noticed to the freight car set, the local traffic with the wagons behind it, at a set that there was a shorted track circuit controller was convinced that the of points. This caused a great deal and had begun to investigation. The freight car set was being shunted for of damage to the track, to a building wagons rolled about 4 km before loading. The result of this was that close to the track and to motor they stopped. the local traffic controller released vehicles along the road. The front The investigation recommended the mechanical brake that held the section of the freight car set (seven exploring the possibility of freight car set in place on the A track freight cars, 194 tonnes, 207 m) developing standards for how (a track mechanical brake in the continued on. One person walking protection should be arranged form of a beam brake that pinches close to the track was hit by the for sidings to prevent vehicles against the freight wagon wheels was freight cars and died. The freight from rolling out onto/near to the used to hold it in place, the parking cars continued through a buffer connecting main line, and further brake was not engaged on any of stop at the end of the track, across analysis of the operators safety the freight cars). The shunter had a parking area, into a container management system in capturing not intended to move the freight car terminal and an associated building. behaviours that can endanger set and had uncoupled the shunting Freight wagons 2 and 3 went over traffic safety. engine. There were no shared the edge of the quayside, across a tug mental models, standard phrases boat and ended up in the harbour or readback-hearback systems in basin, while the rest of the freight place to prevent misunderstandings wagons stopped on the quayside. of communication between the Two people inside the building died, local traffic controller and shunting and four others were injured. The personnel at Alnabru. When it freight cars damaged the building so became clear that the freight car badly that it collapsed. set had started rolling and was not coupled to a locomotive, it was not possible to stop the freight car set by setting a diversion route before it left Alnabru. Nor were there any barriers on the freight train track between Alnabru and Loenga/ Sydhavna which could stop the freight car set in a controlled way. The investigation noted a breach of the ‘no single point of failure’ principle that railway operations shall be planned, organised and performed in such a way that a single failure does not lead to loss of human life or serious personal injury. The basic premise that allowed the accident to happen was the fact that Alnabru was being used in a manner for which it was not originally intended, including structural changes and increased rail freight traffic, combined with a lack of remodelling and improvement of infrastructure to reflect this development. Safety management

20 Estonia Finland Poland www.onnettomuustutkinta.fi

Level crossing collision between Level crossing collision between Fatal level crossing accident in Derailment of passenger train at a truck and a passenger train at a freight train and an articulated Kokemäki Makolowiec Männiku vehicle, Kyrö area of Pöytyä Occurrence date 16 May 2010 Occurrence date 18 Aug 2010 municipality Occurrence date 16 Apr 2010 Investigation release date 27 Apr 2011 Investigation release date 17 Dec 2010 Investigation release date 17 May 2011 Occurrence date 23 June 2010 An electric locomotive collided with The driver of a passenger train Investigation release date 27 Apr 2011 Collision between a passenger train a car at the Koskinen unprotected wrongly interpreted a signal and truck at a passively protected A timber-carrying articulated vehicle level crossing in Kokemäki. The permitting 40 km/h travel over a set crossing, killed the truck driver started to manoeuvre past the half accident was fatal to the car driver of points. The train traversed the and injured a train passenger. The barriers, which were in the lowered and a passenger. A second passenger points at 117 km/h and derailed. investigation determined that the position, when the freight train, was slightly injured. The accident Recommendations were made in direct cause of the accident was which had departed from Kyrö occurred because the car driver relation to fatigue analysis and human error of the truck driver, railway yard in the direction of noticed the approaching train too consideration of in-cab signalling. who could not adequately evaluate Tampere, collided with articulated late and despite braking was not the requirements imposed by the vehicle’s trailer. Both locomotives able to stop the car before the level warning sign of the crossing. An of the train were derailed. The crossing. As the car approached the acute angle between his longitudinal repair costs arising from the damage track the driver was driving too fast axis and the movement direction to track equipment and the level in relation to how visible the track of the train, approaching from the crossing amounted to EUR 150,000. was from the road. Contributing right hand side, was a contributing The decision by the vehicle driver to to this were the inexperience of the factor. The driver, sitting in the cabin start manoeuvring past the barriers driver and the fact that there was of the truck does not have sufficient was apparently influenced by the little indication that a level crossing range of vision to give adequate pressure resulting from being in a was approaching. Underlying evaluation to the traffic situation queue and because the driver felt factor to the accident was that without halting his truck. He drove that the articulated vehicle was visibility to the track was poor without halting at a low speed to blocking the pedestrian crossing. when approaching and insufficient the level crossing and was hit by Other drivers were manoeuvring sightline towards the approaching the train on the right side of the past the barriers, which gave train made the observation more truck. Recommendations included confirmation to the notion that difficult. consolidating crossings for joining the barrier installations were not The investigation recommended the quarry where the truck came functioning properly. The queues action to ensure that road from to the local road network grew to a significant size while the maintenance staff are sufficiently and to apply temporary measures barriers were lowered because the aware of proper level crossing to improve sighting for motor engine driver did not give due regard maintenance as well as the vehicle drivers approaching the to the signal and therefore did not installation of the relevant warning level crossing. notice that the remote controller signs. Safety improvements were had given permission to depart. completed in the surrounding area Once the alarm had been issued that following another accident in 2004. the barriers had been lowered too The number of level crossings in long the remote controller failed to the area was reduced and traffic contact the engine driver or take any was redirected to the Koskinen other action to ease the queue at the level crossing. Redirecting traffic level crossing before the departure of increased traffic and risk exposure the train. at this crossing and the investigation Several safety studies had been noted that such actions should also undertaken of the crossing, dating include upgrading of remaining back to 1996, and the investigation crossings. The investigation also noted that an underpass should notes that there was uncertainty as be built as soon as possible in to which party was responsible for order to solve the traffic problems level crossing maintenance and the encountered at the crossing. clearing of sightlines. > 21 Austria Canada www.versa.bmvit.gv.at www.tsb.gc.ca

Passenger caught in train door, Main-track derailment, Canadian Crossing accident, Canadian Main-track train collision, Vienna line U3 National freight train M-365-21- Pacific Railway freight train Canadian Pacific train number 23 Mile 165.80, Saint-Maurice number 290-14 Mile 13.85, 300-02 and No. 671-037,Mile Occurrence date 7 May 2010 Investigation release date 17 Mar 2011 Subdivision, Clova, Quebec Emerson Subdivision, Grande 37, Mountain Subdivision, KC Pointe, Manitoba Junction, British Columbia A child was caught with one foot in Occurrence date 23 Aug 2010 Investigation release date 14 Jun 2011 a train door. Only when the child hit Occurrence date 14 June 2010 Occurrence date 03 Mar 2010 Investigation release date 14 Jun 2011 Investigation release date 23 June 2011 the barrier at the end of the platform Seventeen cars (16 loaded and one was the child removed from the empty) derailed and approximately A Canadian Pacific Railway freight Train 300 operating eastward door. Recommendations included 1300 feet of track were destroyed. train was struck by a garbage truck side collided with westward Train fitting doors with electrical sensitive About 75 feet behind the last travelling at a speed of at least 60 671. As a result of the collision, 3 edge detectors, as trapped objects derailed car, the track had shifted km/h, as the train occupied the locomotives and 26 cars derailed. with a thickness of less than 50 mm laterally about 12 inches toward passive crossing at Mile 13.85, The locomotive engineer was later are not currently detected on this the outside of the curve. Track near Grande Pointe, Manitoba. air-lifted to a Calgary hospital type of rolling stock, and assessing levelling, tie replacement and As a result of the collision, 22 car in serious condition. It was later whether an optical door closing shoulder narrowing, which were bodies derailed and the fuel tank determined that the locomotive warning system in accordance with not detected during the quality on the second locomotive was engineer had been exposed to EN 14752 should be installed. control performed at the end of the punctured releasing about 4000 marijuana, sometime prior to the The investigation also made a work, weakened the track structure gallons of diesel fuel. The garbage accident. In an attempt to mask this recommendation on the subject of and reduced its capacity to resist truck was destroyed and the driver exposure, he drank approximately retention of testing records for train lateral loads generated by the cars. was seriously injured. The findings 10 litres of water shortly after doors. The rail-neutral temperature in the included that the presence of a the accident, which resulted in derailment area was lowered due structural pillar between the truck’s hyponotremia (water intoxication). to the work and the track became windshield and side window, the The investigation found that the more susceptible to buckling. On large side mirrors and the window collision occurred when train 300 31 August 2010, Canadian National frame on the truck obstructed a large was operated past the stop signal issued new procedures concerning part of the driver’s field of view. at the junction and into the side the action to be taken after ties of train 671. The crew’s attention are laid and a dynamic stabilizer is was momentarily diverted from the used. Before normal train speed is primary task of stopping their train resumed following work, a 10 mph and was likely focussed on resolving slow order must be in place for the a hot box detector issue related to first 2 trains and 30 mph for the the reported hot wheels and not next 2 trains, and the track must be on the impending requirement inspected after the passage of each of to stop the train. The crew on those trains. train 300 conducted numerous cellular telephone communications (voice and text) in the three hour period prior to the accident. While engaged in these communications, the crew operated the train and performed various safety-critical tasks (e.g., negotiating public crossings, complying with temporary and permanent slow orders, and responding to wayside signals). The last communication prior to the accident was completed about 1 minute before receiving the first radio transmission from the signal maintainer concerning the status of the HBD. The report made a finding that despite the existence of rules and protocols regarding the use of personal electronic devices, not all railway employees working in safety sensitive and safety critical positions understand and accept the risks associated with such distractions, increasing the risk of unsafe train operations.

22 Rail Signalling and TSV

Stephen Backway is a rail signal engineer, his responsibilities Application to vary accreditation include assessing notifications of change, applications to vary accreditation and assisting with or performing compliance Section 54 of the Rail Safety Act 2006 (Vic) (RSA) defines the inspections and safety audits. Prior to joining TSV, Stephen requirement of when an ARO is to submit an AVA as: worked for four years with Engineering and Asset Management branch of the Department of Transport. As part of this “…if an accredited rail operator proposes to make a change to, role he completed the Rail Engineering Graduate Program, or to the manner of carrying out, accredited rail operations that which included studying for a Post Graduate Diploma in may reasonably be expected— Rail Signalling, through Central University (a) to change the nature, character and scope of the accredited and gained valuable experience in the industry through rail operations; or secondment opportunities. (b) to not be within the competence and capacity for which the To meet the current demands of the rail environment, the rail accredited rail operator is accredited.” signalling systems regularly undergo change. The changes are In general, for rail signalling projects, an AVA should be often driven by the need to provide greater network capacity, submitted if the signalling project results in a diversion to replace life expired systems and to improve safety. When from current signalling principles or a significant change to a change is to be made to signalling infrastructure (including the signalling system. This includes the introduction of new new infrastructure and changes to the existing infrastructure), technology which is significantly different to the current the accredited rail operator (ARO) is required to submit an signalling technologies. application to vary accreditation (AVA) or notification of change (NOC) to TSV. A review of the AVA is conducted by TSV to verify compliance with the RSA and the ARO’s Safety Management System (SMS). In particular, TSV looks for evidence that the risks to safety have been eliminated or reduced so far as is reasonably practicable (SFAIRP).

It is important in demonstrating SFAIRP that all potential hazards are identified, associated risks assessed, practical controls are identified and justifications for excluding any available controls are provided. A guidance paper is available from TSV, SFAIRP- A Guidance Note and Toolkit (consultation draft). You can find this publication at www.transportsafety.vic. gov.au/publications or feel free to call TSV on 9655 8949 and request a copy to be sent to you.

The review of the AVA by TSV is assessed against general compliance with legislative requirements and does not represent an approval of specific signalling designs. It is the ARO’s responsibility to approve signalling designs and to demonstrate that it has eliminated or reduced the risks to safety associated with the design and operation of signalling infrastructure SFAIRP. This is consistent with the modern legislative approach of the RSA, where the onus is on operators to demonstrate how they have met the requirements of the legislation. > > 23 > TSV’s role is to work with operators to • a high level statement of the scope of • a signalling arrangement plan, which ensure they comply with their legislative works (for example, project brief) details all relevant aspects of the obligations, without prescribing the design, including but not limited to: details, methods or processes by which • a risk register, which includes a overlaps, positions of signals and they choose to comply. comprehensive listing of hazards, aspects they can display, line speeds, risks associated, potential applicable curve speeds, track layout, level TSV’s assessment of AVAs that relate to controls and justifications for crossing protection controls. rail signalling is greatly assisted if the including/excluding the controls following key documents/details are provided: • a description of the operations of the final design, including train types and moves, line speeds and special signal aspect conditions. (for example, operations specification)

24 Notification of Change Past investigations/incidents These risks have been considered and to consider mitigated in recent signalling projects. In general, a NOC should be submitted The following risks are not intended to to TSV when a change is made to the During the identification and treatment be an exhaustive list of risks and are configuration of signalling infrastructure of hazards and risks to safety, it is only discussed briefly by way of general which is within the competence and important to consider new technology information only. capacity of the ARO. This includes and findings from past investigations > changes to the operation and and incidents. Three potential safety maintenance of the signalling system. risks, which have been identified in past For NOCs, additional documentation incidents, are detailed below. may be requested by TSV for compliance purposes and to assist in our understanding of the risks to safety that are associated with the change.

> 25 > Risk: A train exceeds more then twice the Risk: Train exceeds overlap resulting in a Risk: Human error in operation of points diverge speed leading to a derailment or collision with another train. leads to train-train collision or train roll-over situation. derailment. In the past this risk has been This scenario occurred in Laverton, 1976. demonstrated in multiple incidents, with This risk was one of the significant An up Port Fairy train approaching the recent examples including incidents at factors4 in the Ararat (1999) accident. junction at Laverton was routed onto Footscray (2001) and Epping (2002). In A train travelling along the mainline the adjacent line. This was an abnormal both occasions the train ‘tripped’ at the heading for Melbourne, entered the situation and only occurred due to signal, however due to the length of the siding and collided with a stationary shunting operations at a siding further overlap, a train – train collision occurred. train. This accident was attributed to a along the line. The train approached railway employee changing the lie of the the junction at line speed and took the The overlap is a safety margin, which is points from the mainline to the siding, diverging move, at more then twice provided past a signal at stop. The design using the local mechanical levers (and the rated speed and subsequently of which is intended to provide the train annett lock). At this location the points derailed. The Coroner’s report made with a safe distance to stop prior to any were in no way interlocked with the three recommendations to prevent re- danger to trains, people or infrastructure. signalling system or indicated to the occurrence, the third being: The overlaps in these incidents were controller, as such the approaching train designed for a speed lower than line speed was unaware of the lie of the points, until “On lines where maximum speeds exceed (medium speed) and therefore failed to immediately upon them. 50 mph where three position signalling provide protection for when a driver fails is provided, modify the signalling to respond to the warning aspects on prior As a result of this accident, reviews arrangement so that medium speed signals. This risk is more predominate of similar locations were undertaken crossovers are so signalled as to provide at stopping locations (home signals or in Victoria and suitable controls were a stop signal for the crossover move for platforms) or at converging junctions, due implemented to eliminate or reduce the sufficient time to ensure that the Driver to the higher frequency of stopped trains risks appropriately. in observance of that signal reduces the and previous design practices. Footnotes speed of the train to a safe level.”1 The relevant recommendations include: 1 Source: Laverton, Derailment UP Port Fairy In this situation, the rated speed of the • Footscray ATSB Investigation report, Passenger Train, 10.5.1976, Summary of diverging move was 25mph. The specific recommendation 4: Coroner’s Board of Enquiry Evidence 2 Source: Rail Investigation Report, Collision control stated in the recommendation “The signalling system and overlap should between suburban electric passenger train may not apply to all situations however, be reviewed with a view to ensuring trains 6369 and the empty express electric train 6371, it is important to treat the risk presented passing a signal at danger are stopped within Footscray, Victoria, 5 June 2001, ATSB, Nov a safe distance. In sections before a station in this scenario. 2001 this distance should ensure a train is brought to a halt before a possible collision with 3 Source: Rail Investigation Report, No 2002/001 another train stopped at the station.”2 – Collision Between Suburban Electric Passenger Train 1648 and Suburban Electric • Epping ATSB Investigation report, Empty Train 1025 – Epping, Victoria, 18 June recommended safety action 2002, ATSB, April 2003 RR20020002: 4 Source: Rail Investigation Report, R1/2000, Collision Between Freight Train 9784 and “The ATSB recommends that the Department Ballast Train 9795 – Ararat, Victoria, 26 of Infrastructure review the design of the November 1999, ATSB, March 2000 signalling system, including the safety margin and route interlocking, particularly on single line sections of track with only one signal protection from oncoming movements.”3 > 26 27 Safety issues at rail level crossings are In recognition of the safety issues at TSV supports a key concern for TSV, the Victorian level crossings, the Monash University Government, the wider rail industry Accident Research Centre (MUARC) and the community. Upgrades to level received funding from the Australian innovative crossing protection are expensive and Research Council to conduct research on compete with other important projects human factors issues at level crossings. research for limited government resources. The research is a partnership between Therefore, new ways to improve safety MUARC and a number of organisations at level crossings are a high priority. that are providing funding or in-kind into motorist New and innovative countermeasures support for the project. are proposed at regular intervals, and behaviour the implications of these for road user behaviour and level crossing system at level safety must be assessed systematically. crossings

28 The organisations are: In June, 2010, Monash University received The knowledge developed during the funding for the project, “Application of project will include a world-first model of • TSV contemporary systems-based methods to the level crossing system and will support • VicTrack reduce trauma at rail level crossings”. the development of countermeasures that will improve safety. TSV looks • Department of Transport (DOT) This research will be conducted over four forward to the findings of the research years and aims to develop a systems- and seeing these implemented. • V/Line based model of railway level crossing performance that accounts for road user • VicRoads behaviour, the factors that influence road • Transport Accident Commission (TAC) user behaviour (such as signage, the types of protection provided, the sighting • University of Southampton distance on the crossing), and the factors (in the United Kingdom). known to lead to incidents and accidents. The model will be used to prioritise current and new countermeasures. A proportion of these will be formally tested using additional methods of assessment.

29 Failure of bridges > due to scour

Scour is the loss of foundation material (that is, soil and rocks) from around bridge abutments or piers caused by the flow of water over time. It can lead to the undermining of bridge foundations and has been the cause of numerous catastrophic bridge failure incidents.

Recent incidents that have identified scour as the main causal factor include the River Crane Bridge collapse in UK (November 2009) and the Malahide Viaduct collapse in Ireland (August 2009). >

30 > River Crane Bridge collapse UK • an obstruction in the watercourse, As a consequence of this accident the which channelled the flow towards RAIB made five recommendations to The Rail Accident the east abutment, increasing its Network Rail: velocity and making it more likely Investigation Branch (RAIB), that scour would occur • mandating frequent checks for 1 obstructions against the upstream Rail Accident Report , • Network Rail being unaware of the faces of bridges identified the following obstruction and therefore not taking action to mitigate the risk of scour • improving the annual assessment contributing factors: process for structures to ensure • the vulnerability of the east abutment that key personnel have sufficient of the bridge to undermining by information to undertake the scour by virtue of being located on task competently. The river crane the outside of a bend in the river, report found it was unreasonable constructed with shallow foundations to expect scour to be detected by and founded on erodible material track patrollers undergoing routine inspections • the absence of checks by Network Rail staff for obstructions against the • introduction of a means to prompt upstream faces of bridges members of the public to report obstructions • weaknesses in Network Rail’s process for annual assessments of structures, • improvements in Network Rail’s particularly the information provided process for managing scour risk to the individuals involved • improvements in the guidance • Network Rail having inadequate provided by Network Rail to staff who knowledge about the condition of may have to evaluate whether it is the foundations of the bridge as they safe to run trains in the immediate had not commissioned mandatory aftermath of an incident. underwater examinations The RAIB has also made one • the lack of a mechanism to encourage recommendation targeted at the members of the public who were Environment Agency covering the aware of the obstruction to report it introduction of arrangements for to Network Rail reporting obstructions to railway infrastructure owners, regardless of • Environment Agency staff not whether there is a risk of flooding. being aware of the safety risk presented by the obstruction found in the watercourse at the bridge and not being under an obligation to report non-flood risks to the infrastructure owner. > > 31 Malahide Viaduct • information regarding the bridge The factors listed above contributed to > collapse Ireland was missing due to there not being a the bridge collapse due to scour and properly introduced information asset highlight the importance of assessing and The Railway Accident management system managing risks associated with scour. It can be difficult for bridge inspectors to Investigation Unit (RAIU) • the IM failing to meet all of the check for scour during scheduled bridge requirements of its inspection in Ireland, investigation inspections due to access difficulties and standard: visual inspections were not the possibility of infilling, that is the void report ‘Malahide carried out for all visible elements of created by scour has been filled by loose Viaduct Collapse on the structures, bridge inspection cards soil and sediment making the void appear for recording findings of inspections Dublin to Belfast Line’, filled. IMs are therefore advised to were not completed to standard or implement a scour risk management plan 2 dated 21 August 2009 , approved by the relevant personal. as part of their bridge inspection regime. A formal program for systematic identified the following visual inspections of all elements Footnotes contributing factors: of a structure, including hidden or 1 Source: Laverton, Derailment UP Port Fairy submerged elements, despite an Passenger Train, 10.5.1976, Summary of • the infrastructure manager (IM) independent review recommending Coroner’s Board of Enquiry Evidence had not developed a flood/scour the IM implement this program 2 Source: Rail Investigation Report, Collision management plan in 2006. between suburban electric passenger train 6369 and the empty express electric train 6371, • engineers were not appropriately The RAIU made 15 recommendations, Footscray, Victoria, 5 June 2001, ATSB, Nov trained for inspection duties, in that some of which are summarised below. 2001 the inspections training course they The full list of recommendations can be 3 Source: Rail Investigation Report, No completed was an abridged version found in the investigation report. 2002/001 – Collision Between Suburban Electric of the intended format, and there Passenger Train 1648 and Suburban Electric was a not formal mentoring program • the IMs should remove the Empty Train 1025 – Epping, Victoria, 18 June 2002, ATSB, April 2003 for engineers on completion of requirement for track patrollers to this course check for scour 4 Source: Rail Investigation Report, R1/2000, Collision Between Freight Train 9784 and • there existed an unrealistic • the IMs should formalise their Ballast Train 9795 – Ararat, Victoria, 26 requirement for patrol gangers to guidance standard for inspections and November 1999, ATSB, March 2000 carry out annual checks for scour, as reissue to all relevant personnel Endnotes they did not have access under the 1 Rail Accident Report 17/2010, Failure of Bridge structure and in addition, they did not • the IMs should introduce a RDG1 48 (River Crane) between Whitton and have the required specialist training/ verification process to ensure that all Feltham, Rail Accident Investigation Branch (RAIB), Department for Transport (UK), 14 skills to identify defects caused requirements of their standard are November 2009. by scouring carried out in full 2 Investigation Report No. R2010 – 004, Malahide • the IM’s suite of structural inspection • the IMs should carry out inspections Viaduct Collapse on the Dublin to Belfast Line, st standards providing guidance for for all bridges subject to the passage on the 21 August 2009, Railway Accident Investigation Unit (RAIU), August 2010. inspectors carrying out inspections of water for their vulnerability to was not formalised scour, and where possible identify the bridge foundations. A risk-based • a formal program for special management system should then be inspections for structures vulnerable adopted for the routine examination to scour was not adopted, as per the of these vulnerable structures. IM’s inspection standard at the time of the accident.

The report also stated that the underlying factors to the accident were:

• loss of corporate memory when the IM’s staff left the division, which results in valuable information to the historic scouring and maintenance not being available to the staff in place at the time of the accident

32 33 Variation of Accreditation for complex projects

Background An ARO must not implement the change • ongoing compliance with the to, or to the manner of carrying out, their requirements of the RSA throughout An accredited rail operator (ARO) must accredited rail operations unless the AVA the project by the ARO and any other submit an application for variation of has been granted by TSV. party that is involved in the project accreditation (AVA) to TSV when they (for example, contractors engaged in Following submission of the AVA, TSV propose to make a change to, or to the design and construction activities). may request that the applicant supply manner of carrying out, their accredited additional information regarding Engagement well ahead of the formal rail operations that may reasonably be the proposed change. Based on the submission of the AVA will promote a expected: information provided, TSV must make a more comprehensive understanding • to change the nature, character decision whether or not to grant an AVA: of the project and also provide an and scope of the accredited rail opportunity for the ARO (and any other • within six months of the initial operations, or parties to the project) to demonstrate application being received by TSV how the risks to safety associated • to not be within the competence • within six months of TSV receiving with the project are being eliminated and capacity for which the ARO is the last of any further information or reduced ‘so far as is reasonably accredited (s54(1) Rail Safety Act requested (or another period agreed practicable’ throughout the project. This 2006 (Vic) (RSA)). by both parties), or may be demonstrated by: Examples of significant proposed • a time period set by TSV so long as • implementation of appropriate changes to accredited rail operations TSV notifies the applicant in writing processes to identify hazards, assess which require the submission of an AVA of the extension before the relevant risk, assess controls and make include: six month period expires- decisions for rejecting, implementing and reviewing controls, to replicate • geographic change to rail operations whichever is longer (s54(5) and (9) RSA). steps in SFAIRP guidance e.g. a new line or extension to a rail corridor AROs are therefore strongly advised • the elimination or reduction of to take the requirements of any AVA hazards and risks by design • maintenance or construction activities into consideration when planning their not currently undertaken project timelines in order to avoid • incorporation of appropriate controls to eliminate or reduce hazards and • increasing train running speeds TSV’s review causing a delay to project implementation. the risks to safety at the design stage • new signalling or safe working system • implementation of appropriate • new communications systems Complex projects processes for managing the design, development and implementation of • new train stations or new types of For more complex or larger projects, the system or infrastructure tram stops consultation with TSV should commence as early as possible (such as the project • the effective identification and • a change in the rail operations which planning stage), and continue on a management of problems and issues could result in the ARO no longer regular basis until the ARO’s AVA has that often occur during the design having the competence or capacity been granted by TSV. Engaging TSV early and development of complex projects. to maintain the safety of their ensures: operations With a more comprehensive • TSV can identify and raise any understanding of the project and • new types of rolling stock, including concerns that may affect the exposure to the risk management maintenance vehicles accreditation of the project as early process, TSV will be in a better position to quickly review, assess and process • changing from a freight operator to a as possible (when any issues may the ARO’s AVA making it more likely that passenger rail operator be more easily and cost effectively addressed), in order to avoid delays overall project timeframes will be met. • an alteration to working when the AVA is sought by the ARO, arrangements for train crews e.g. two and persons to driver only operation.

34 Mudholes

Mudholes are sections of track where track buckling, during periods of high the ballast has been fouled by mud. ambient temperature. Comments, ideas, feedback? Mudholes can be formed by failure of the Need this publication in a more capping layer and formation. This may be From a safety perspective, if track accessible format (such as large caused by: geometry is not maintained to print or audio)? Please telephone specification, there is an increased risk of TSV on (03) 9655 2050, or email • poor drainage in the track section derailment of trains. [email protected]. causing saturation, degradation and gov.au subsequent failure of the capping There are a range of controls that can be layer and formation implemented to manage the immediate Report a rail safety incident risk to safety associated with track (accredited rail operators only): • damage to the capping layer geometry defects arising from mudholes. 1800 931 937 and formation caused by track These include: Stay informed. Subscribe to TSV’s maintenance, or • reducing train speed email alerts service: Go to the news • damage to the capping layer and alert subscription form on the TSV formation caused by rail defects such • increase in the frequency of track website and tick the ‘rail’ box. as dipped welds or corrugations. inspections, and View previous editions of this When a loaded train hits the • recording and analysis of track newsletter: Go to the TSV defective rail, it generates a severe geometry data generated by a track website homepage, then click on impact which penetrates the ballast, recording car operated at regular ‘publications and forms’ formation and sub-grade, and over intervals. (top right-hand corner). time causes damage and degradation. Risks associated with the above controls Rail Safety News is published by Transport Safety Victoria. When the formation and sub-grade include a track geometry defect going fail, these materials migrate through Authorised by the Director Transport Safety. undetected between track inspections © Copyright Transport Safety Victoria. This publication is the ballast and retain water, creating or running of the track recorder car. copyright. No part may be reproduced by an process except a mudhole. The track maintainer should ensure that in accordance with the provisions of the Copyright Act 1968. ISSN 1835-4483 this risk is managed by ensuring that the Mudholes can also be formed by dirt This publication is intended as a general information blown from adjacent fields or cess drains level of track monitoring is appropriate source. While every effort has been made to ensure that for the track conditions, and that safety the material contained therein is accurate and up-to-date, or from ballast wear, fouling the ballast. Transport Safety Victoria accepts no responsibility or legal performance indicators are regularly liability for the accuracy or completeness of the information One of the key functions of ballast is to assessed to provide an objective contained in this publication. This publication does not contain legal advice or professional advice, and should not hold the sleepers securely in position and measurement that the track geometry be treated as such. to ensure there is minimal movement of defects are being managed so far as is the track when it is subject to: reasonably practicable.

• vertical and lateral forces generated Emerging technologies are increasingly by the passage of trains or being used internationally, such as track geometry measurement systems, fitted • the forces generated by the expansion to in-service rolling stock, enabling and contraction of the rail due to continuous measurement of track changes in ambient temperature. geometry under the passage of a loaded The development of mudholes can vehicle. adversely affect the ballast’s ability to While reducing train speed may increase hold sleepers in position and maintain travel times, it is an effective control to vertical or horizontal track geometry. ensure the safety performance of the rail Failure of the ballast to hold the network affected by mudholes. sleepers securely in position can result in the track moving excessively in the vertical direction under load (which is characterised by rough ride on trains) or

35 Rail Safety News cow

Rail Safety News has been getting some “… PS We did like to ruminant in the As yet, our Rail Safety News cow is great feedback, and our Rail Safety cow hard-hat. However, she did seem a bit nameless, and we invite you to send from issue 5 has been very well received. close to the railway line (and no hi-vis us your suggestions for a suitable So much so, we have had inquiries as to vest). Maybe we can let her off, as there appellation via email: her well-being and her name! Here’s one were no udder cows about. [email protected] such example from Rowan Bravington, Secretary Rail Safety Accreditation, Regards Mornington Railway. Rowan”