Public Safety Annual Safety Review 2007 Victoria was the first State to introduce the Rail Safety Act on 1 August 2006. 2006-07 performance outcomes The central theme for > The Accreditation and Audit team Safety Victoria (PTSV) outcomes for conducted 961 bus compliance audits 2006-07 is the successful implementation under the requirements of the Public and administration of the Rail Safety Transport Competition Act 1995. Act 2006. In accordance with this theme These audits are designed to ensure the following are some of the highlights that operators are: of PTSV’s first full year of operation: – meeting the standards and conditions > PTSV developed an Accreditation of accreditation Guideline which provides guidance on – complying with maintenance the accreditation aspects of the new management systems rail safety including risk – complying with management and change management. information systems > PTSV developed and agreed a series – having their inspected by an of milestones for commercial rail independent tester every 12 months. operators to achieve during the two year > The Rail Audit and Compliance team phase in period. conducted 42 safety audits. These audits > PTSV is developing a catastrophic are designed to ensure that operators: risk model and Contributing Factors – meet competency standards for rail Framework to enable more sophisticated safety workers analysis of incident trends and data. – meet maintenance standards > Victoria was the first state to introduce –  have self audit systems in place the Rail Safety Act on 1 August 2006. –  risk registers are regularly reviewed and that controls are complied with.

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Contents 2006-07 performance outcomes 01 Director’s foreword 04 Vision and mandate 06 09 Background 10 Our organisation 12 2006-07 acheivements 14 Rail 19 Bus 23 Looking ahead 27 Appendix one – heavy rail safety statistics 31 Appendix two – safety statistics 33 Appendix three – bus safety statistics 34 Appendix four – significant train/tram /bus incidents 35 Appendix five – Improvement notices issued 2006-07 35 Appendix six – output performance measures 36 Data sources for statistics 37

Acronyms ARA Australasian Railway Association AQTF Australian Qualification Training Framework CFF Contributing Factors Framework COAG Council of Australian DCQP Data Collection Quality Project DIRN Defined Interstate Railway Network DOI Department of Infrastructure ERS Electronic Reporting System ITSRR Independent Transport Safety and Reliability Regulator LBT Licensed Bus Tester MMS Maintenance Management System NTC National Transport Commission NCR Non Conformance Report PTSV Public Transport Safety Victoria RRM Rail Resource Management RSRP Rail Safety Regulators’ Panel TSAARS Transport Safety Accreditation Audit and Reporting System TSO Transport Safety Officer VCAT Victorian Civil and Administrative Tribunal 3 Our objective is to build upon an already good safety record of rail and bus transport in Victoria. Director’s foreword It is an honour and a privilege to A number of new processes and procedures We must reflect on the tragic fatal rail introduce Public Transport Safety have been created within PTSV to enable accident at Kerang in June 2007 in which Victoria’s first Annual Safety Review. the effective administration of the rail 11 people were killed when a truck collided The purpose of these annual reviews is safety legislation, along with the creation with a passenger train at a . to give our stakeholders an account of of a new brand identity and communication The accident is still under investigation by PTSV’s work over the year and to provide a mechanisms such as our new website. various authorities. A number of initiatives platform for the regulator to reflect on this PTSV has also contributed to the bus safety have begun to address road driver behaviour vital industry, and to flag future priorities as legislative review with the intention that at level crossings. we see them. any new legislation should build on the The priorities for PTSV next year are to: It has been a busy year for PTSV following successes of the current safety legislation. > achieve the final milestones for each rail the formation of the new statutory office The bus industry in Victoria has a very good operator to maintain its accreditation under the Rail Safety Act 2006. Victoria is the safety record and PTSV is looking forward to > continue to monitor the safety of our first State to put new rail safety legislation in new legislation being developed in 2008 to level crossings place based on national model legislation. provide a refreshed regulatory regime under > prepare for new bus safety legislation which the industry will continue to thrive. This legislation is the first to be enacted in > ensure that safety is a central feature of any Australian to reflect the draft We have also invested in the development the refranchising planning process for legislation developed as part of the Council of our people to ensure that we have the the metropolitan area of Australian Goverments (COAG) directive. right skills and experience to realise our > work with industry on raising the quality vision of being a respected transport safety of accident investigations to ensure that Other States will follow through 2007 and regulator that is proactive and risk-based. maximum learning is gained 2008 and Victoria continues to play a lead We are only at the beginning of this journey > continue to build effective role in the national program. PTSV has but we are making good progress. relationships been working closely with the Victorian rail industry to ensure a smooth transition to the The rail industry (which also includes ) I would like to thank Tom Sargant from the DOI new duties contained in the legislation. in Victoria is rising to the challenge of the who filled the position of Acting Safety Director rail safety legislation and PTSV continues through a crucial period in the lead up to the to monitor industry’s implementation of enactment of the Rail Safety Act 2006. the transitional milestones put in place I am also grateful for the considerable after the rail safety legislation was support we continue to receive by being enacted. Our objective is to build upon an administratively linked to the Department already good safety record of rail and bus of Infrastructure. transport in Victoria.

Alan Osborne Director, Public Transport Safety

5 Vision Mandate To be a respected transport To continuously improve safety regulator who is proactive the safety of public transport in Victoria. and risk based. This mandate will be implemented by: PTSV will achieve this by being: > effective regulatory intervention > a credible and industry > proactive respected regulator > targeted communication and education > risk based, prioritised and benefit driven > an agile and responsive organisation > a collaborative and unified organisation

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Did you know? > Metropolitan train patronage has increased by 23 per cent over the last two financial years. > Metropolitan bus patronage is at a 40 year high. > Patronage on regional trains and coaches has grown by 29 per cent since last financial year. Governance The journey so far... Prior to the 1990s bus services were operated by both and private operators. Government bus services were progressively privatised from late 1993. Historically tram and rail were operated by the state government via the Public Transport . In 1998 tram and rail services were corporatised and initially operated as government run businesses and subsequently were privatised in 1999. In 1998, the Office of the Director of Public Transport within the Department of Infrastructure (DOI) administered safety . The office had no powers of prosecution or intermediate enforcement actions, such as issuing prohibition or improvement notices. In 2006 the Office of the Director of Public Transport Safety was established by the . The aim was to create a statutory office with greater independence from the government, with powers to regulate, enforce and provide a direct line of for public transport safety in Victoria. PTSV is administratively linked to the DOI and utilises its IT, financial and human resource services. The key DOI governance processes such as its Audit Committee also review PTSV’s risks through its audit mechanisms. PTSV has an Executive Committee which meets every two weeks to ensure that objectives are being achieved and risks to their achievement are effectively managed.

9 Background Rail industry Bus industry Victoria’s rail network is ’s second Victoria’s bus industry consists of 1,562 largest with 26 commercial and 19 accredited bus operators overseeing the tourist and heritage accredited operators. operation of more than 9,200 buses. The commercial operators provide all of More than half of these operators provide the state’s passenger and freight services. route, school-bus, touring and Operators can be accredited as rolling stock services. The remainder are non-commercial operators and/or rail infrastructure managers operators who provide private, courtesy, under the Rail Safety Act 2006. and hire and drive services. Patronage has increased significantly across The bus industry is currently undergoing the rail sector as the state government a wider regulatory reform process. implements aimed at transferring It is anticipated that the revised bus freight from road to rail, and providing legislation will give PTSV similar compliance, incentives for commuters to use public enforcement and education responsibilities transport instead of driving to major activity to those applied to the rail industry under centres. Increasing demand and more the Rail Safety Act 2006. services means that the requirement for a Role of the safety regulator vigilant and well managed safety regulatory system is paramount in the provision of safe The primary purpose of safety regulation services for Victorians. in the public transport industry is to create a framework within which the industry The Rail Safety Act 2006 stipulates that effectively manages risk. An effective operators must have appropriate safety safety regulator ensures a safer system management systems, including risk for all users. assessments and reporting regimes, to ensure that they can continue to operate PTSV’s goal is to use risk management safely. PTSV’s role is to initially guide as the basis for its regulatory activities, operators through the Act’s provisions and including accreditation and compliance to ensure that operations are safe so far activities. It monitors compliance as is reasonably practicable. through a system of inspections and audits of operators. PTSV is also a source of advice and guidance for industry with regard to safety management and the responsibilities for operators under the rail safety legislation.

10 Increasing demand and more services means that the requirement for a vigilant and well managed safety regulatory system is paramount in the provision of safe services for Victorians.

11 Our organisation In 2006-07 PTSV took a consultative Public Transport Safety Victoria Executive Team approach to creating a new organisation charged with the responsibility for regulating the safety of Victoria’s public The Hon. MInister for Public Transport transport system. PTSV renewed its focus on the core business of safety operations and Alan Osborne creating the technical support to drive Director interventions through risk and information. This focus has seen the creation of new support branches within PTSV such as communications and business support. Jennifer Patterson Melanie Mills Stephen Turner Chris McKeown Rosa Costanzo Manager Regulatory Manager GM Safety Operations GM Safety Systems Manager Business PTSV’s 64 staff are responsible for & Legal Communications regulating the 1,562 accredited bus operators and the 26 commercial and Includes the areas of: Includes the areas of: > Bus Audit & Accreditaion > Human Factors 19 tourist and heritage accredited rail > Rail Accreditaion > Safety Information Systems > Rail Audit & Compliance > Technical specialists in operators across Victoria. > Investigations rail & bus infrastructure, risk & operations

Education, training and recruitment Staff who are trained to a Certificate IV level During the year PTSV filled key leadership PTSV has continued to implement an in training and assessment are nationally positions and focused recruitment activities integrated education program for regulatory recognised and qualified to deliver training on accreditation and audit capabilities staff with 17 PTSV staff having been sessions. A number of PTSV staff have particularly in four key regional areas: awarded the Diploma of Government years of experience and expertise that are – Barwon South Western Region (with specialisations in compliance and important to assist others in the delivery of a – Loddon Mallee Region investigation, and project management). formal education and training regime. – Eastern Region In conjunction with the Diploma, nationally All new starters and Transport Safety – Hume Region recognised training has been provided Officers (TSO) to PTSV are trained in legal Media and communications to ensure PTSV staff are equipped matters. New starter training includes a A communications business unit was with the appropriate qualifications and legal awareness session covering statutory developed in early 2007 to manage PTSV’s competencies to carry out their duties interpretation, using legal advice, legal communications, media and stakeholder (such as lead auditor, risk management, professional privilege, and natural justice. functions. The area supports the overall education and assessment and transport TSO training includes powers under the operations of the organisation by providing management training). Transport Act 1983 and Rail Safety Act 2006; communications advice on numerous what is evidence; collecting evidence; projects including the development of issuing improvement and prohibition notices; a PTSV website and visual identity as well and giving evidence in a tribunal hearing. as issues management. This section of the TSO training concludes with a mock hearing in the Victorian Civil and Administrative Tribunal (VCAT).

Staff competencies 2006-07

Qualification Number of staff completed Diploma in Government 17 Diploma in Government – Project Management 5 Diploma in Business (Quality Auditing) 3 Transport Safety Officer Training 8 Certificate IV in Training and Assessment 5 staff currently undertaking the course with one having successfully completed it

12 Growth in skilled labour is slowing and is expected to drop to 0.4 per cent per year by 2016. This means attracting, maintaining and nurturing talent in the organisation is an important aspect of the PTSV business plan.

13 2006-07 objectives 2006-07 achievements > Improve the efficiency and Strategic business vision Introduction of the Rail Safety Act 2006 effectiveness of PTSV’s During the year PTSV established a and Rail Safety accreditation, audit, compliance comprehensive vision, mandate and The Rail Safety Act 2006 and Rail Safety and investigation activities organisational direction for the next five Regulations became operational on > Improve PTSV’s organisational integrity, years. PTSV’s strategic planning involved all 1 August 2006 and since that time PTSV governance and accountability of the PTSV team, enabling the organisation has been responsible for implementing and to identify and prioritise future activities and administering their provisions. > Identify and provide appropriate address organisational gaps and challenges. training, information and Rail operators and infrastructure managers education activities Audit and compliance who held accreditation prior to 1 August 2006 are currently participating in a staged > Define a risk-based decision During 2006-07 PTSV has undertaken a number of activities to improve the way transition process to comply with the making process for PTSV’s requirements of the rail safety legislation operational functions in which safety audits and compliance inspections are undertaken. by mid-2008 (2009 for tourist and > Identify the most significant safety- heritage operators). These improvements include a review related trends and risk factors in rail of all operational standard procedures, Accreditation transition arrangements and bus safety in Victoria development of a best practice TSO Under the provisions of the Rail Safety > Maintain high level awareness of training program and further professional Act 2006, existing rail operators have research and development in rail and development of accreditation and been provided with a transitional period to bus safety regulation and worldwide compliance management staff. meet the full requirements of the new Act engineering solutions In addition, the TSO’s primary tool, the and legislation. > Create a work environment that Compliance Manual, has been reviewed Four transitional milestones have been develops motivated and highly and amended to reflect the needs of the developed and agreed upon by commercial skilled people Rail Safety Act 2006 and the natural justice, rail operators to assist this phase. The first fairness and probity requirements of the milestone involved each operator developing Human Rights Charter Act 2006. an implementation plan which was completed in the latter part of 2006-07. The second milestone required the commercial rail operator to conduct a gap analysis of their existing safety management system against that required under the rail safety legislation. The responses identified safety policy, emergency management, safety governance, management of change and risk management as the elements that most rail operators need to address.

14 The third transitional milestone required the National agenda Rail Safety Regulators’ Panel commercial rail operator to submit their risk PTSV has had an active role in the national The RSRP consists of representatives from management processes for review and to agenda for the development of rail safety each of the Australian and New Zealand rail date, no organisation has been found to be legislation. PTSV has represented Victoria safety regulators’ offices. It meets quarterly fully compliant with the risk management at the National Transport Commission (NTC) and encourages informal mechanisms for requirements of the new legislation. Rail Safety Package Steering Committee. communications outside of these more The fourth milestone requires each operator Each jurisdiction was required to have formal meetings. to provide PTSV with a full compliance implemented its own legislation reflecting The RSRP has worked to foster a consistent report. These are due for completion in the substantive provisions of the national regulatory approach throughout the various December 2007. model rail safety legislation by 1 July 2007. , and drive the practical To assist existing tourist and heritage rail Victoria is well ahead of this target, having implementation of the national rail safety operators to transition to the rail safety commenced the Rail Safety Act on 1 August legislative reforms. legislation, the Public Transport Division 2006. In addition, PTSV has assisted in of the Department of Infrastructure has the development of national guidelines, appointed consultants to support and which will sit under the national legislation. work with tourist and heritage operators in In addition to leading the development of meeting accreditation requirements. the National Guideline for Accreditation and the National Compliance and Enforcement Policy for Rail Safety, PTSV contributed to the development of the: > National Guideline for establishing a Rail Safety Management System > National Guideline on the Meaning of So Far As Is Reasonably Practicable (SFAIRP) > National Business Rules for Uniform Administration of Accreditation > National Guideline for Fatigue Management for Rail Safety Workers It is expected that the ongoing maintenance of the national guidelines, and the development of further guidelines, will be overseen by the Rail Safety Regulators’ Panel (RSRP).

15 Accreditation Guideline Guide on the Preparation of an PTSV has developed an Accreditation Emergency Plan Guideline, which provides guidance on PTSV commissioned consultants to assist the accreditation aspects of rail safety in producing a Guide on the Preparation legislation, and appends a series of of an Emergency Plan. documents on subjects such as risk The aim of this Guide is to advise rail management and change management. infrastructure managers and rolling stock PTSV has also developed a series of operators of their obligations under the milestones for commercial rail operators to rail safety legislation, in the preparation, achieve during the two-year phase in period. communication, keeping, maintaining, The introduction of the milestone approach testing and review of an Emergency Plan. was accompanied by a series of one-on-one The Guide details what constitutes an visits by PTSV staff to operators explaining acceptable Emergency Plan and the the new regime and PTSV’s expectations. necessary information to be included in These sessions also provided operators the various stages of the preparation of with the opportunity to raise any issues and an Emergency Plan. It also identifies the concerns regarding the new legislation. various stakeholders to be involved in the Private sidings preparation and communication of the plan. The rail safety legislation introduced new PTSV is currently consulting with industry on safety obligations for operators who operate this plan and it is anticipated that it will be solely in private sidings. PTSV has been available in early 2008. working with the industry to advise them Catastrophic Risk Modelling Project of the changes and assist them in complying This project has been developed so that with the new requirements. PTSV can identify the key risks to rail safety A private siding is an area where trains can in Victoria. The project will then examine be loaded and unloaded that is managed by which risks are the most critical and someone other than the infrastructure and likely to occur. This work will inform PTSV rolling stock operator. An example is where interventions when monitoring safety across goods are loaded onto freight trains. the rail system. Some of the key work that Private siding operators had to lodge an has been undertaken for this project so application for accreditation or an application far includes: for exemption from accreditation under > train to train collisions the rail safety legislation by 31 October > derailments 2007. It is expected that all persons > the risk of trains striking terminal who carry out rail operations in private infrastructure (eg. buffer stops at the end sidings will be accredited or exempted of a train line) from the requirement to be accredited by > trains striking objects on the track other 31 December 2007. than at level crossings > rolling stock accessing the track from yards and sidings > passenger train fires

16 Drug and alcohol training Safety Alerts issued 2006-07 PTSV has continued to promote a program Safety Alerts are a communications tool that in conjunction with an external organisation, PTSV uses to advise rail operators of critical to provide training and assist assessing safety information. They are issued to rail officers in rail organisations to administer operators via email as required. All alerts drug and alcohol provisions under the rail from September 2007 can be viewed on safety legislation. the PTSV website. Assessing officers are TSOs appointed by During 2006-07 PTSV issued the following the Safety Director solely for the purpose of Safety Alerts to Victoria’s rail operators. applying the drug and alcohol provisions of the rail safety legislation. 2006 Failure of AQEY wagon 2006 Failure of auto coupling of a CQBY wagon 2006 Wheel defect found on an R7E3S type wheelset 2007 Operation of the signalling telemetry system following an incident in WA 2007 Clarification of Section 15 part 5 of the Book of Rules and Operating procedures 1994 2007 Fibrous wear pads and liners in rolling stock 2007 Potential for the presence of asbestos bonded material in rolling stock 2007 Wrong side signalling failure of tri-colour LED signal unit

17 Research Pedestrian behaviour study at public Springvale Road level crossing Contributing Factors Framework railway crossings camera studies Rail operators conduct systemic PTSV and independent consultants In September 2006, PTSV presented investigations in order to identify undertook a study of pedestrian the observations and findings of organisational contributors to behaviours at level crossings. On-site camera studies at the Springvale Road, accidents. The Contributing Factors interviews with members of the public Nunawading level crossing at the 9th Framework (CFF) will provide rail safety were undertaken by members of PTSV International Level Crossing Safety investigators, accredited rail operators to understand behaviours at pedestrian Symposium in Montreal. and regulators with a nationally crossings. The study observed the Driver behaviour at this crossing was consistent, structured framework and behaviours of people in different age observed for compliance with the process to record the contributing groups and at crossings with differing road rules. The study found that by factors identified during the systemic types of control. controlling road traffic flows through investigation of rail safety occurrences. The key findings show that: the use of pedestrian operated signals The CFF is now at a stage where it needs > 31 per cent of people admitted to placed prior to the crossing lessened to be rigorously tested and reviewed by crossing tracks when a train was the number of vehicles queuing over a wider group of potential users. This coming, mainly because they were the crossing. process will be used to further develop in a hurry Rail Resource Management the Framework, and to test its practical > males were more likely to offend PTSV, jointly with the New South applications and usefulness in recording than females Wales Independent Transport Safety the contributing factors identified from and Reliability Regulator (ITSRR) is > people were more likely to cross when systemic rail safety investigations. working with the Australasian Railway a train was approaching at a passive Testing is being undertaken with a range Association (ARA) and the rail industry control crossing than where there is of accredited rail operators. on a national project to provide best active protection A road test of the framework will be practice applied human factors training > 18 – 25 year olds are most likely rolled out early in 2008. materials for rail safety workers. to cross the tracks when a train The CFF has been developed by the The project is endorsed by the National is coming Rail Safety Regulators’ Panel. Rail Safety Regulators’ Panel. Guidelines > 42 per cent of those surveyed have and the interim report for the Rail witnessed somebody being caught on Resource Management (RRM) are the tracks when a train was coming. available at www.ptsv.vic.gov.au. Further work following this study is This initiative will be launched in being conducted by PTSV into human December 2007. factors issues at level crossings. Rail

19 Rail audit and compliance Compliance inspections conducted 12 April 2007: Level crossing collision activities for 2006-2007 during 2006-07 involving Yarra Valley Tourist & Heritage The purpose of a compliance inspection A trolley car carrying seven passengers Safety audits conducted 42 is to determine if there have been any and two crew was struck and derailed by a motor car at the Mirror Rd level crossing. Compliance inspections conducted 29 breaches of rail safety . Of the 29 compliance inspections undertaken, seven PTSV attended the incident and conducted a Non Conformance were the result of responses to incidents. compliance inspection. Reports (NCRs) raised 135 The remainder were reviews of findings 3 May 2007: Oakleigh train derailment Improvement notices raised on safety audits or targeted inspections A Connex train derailed near Oakleigh station (refer to Appendix five) 13 responding to trends in the industry, such as at a set of points when an alternate path was New accreditations 6 fatigue management. set following the failure of a home signal. 26 October 2006: North rail PTSV attended the incident and conducted Safety audits safety worker injury a compliance inspection. There were 45 scheduled audits for PTSV conducted a compliance inspection to 21 May 2007: Mildura freight train 2006-07. Three were cancelled due to investigate the circumstances surrounding derailment operators surrendering their accreditations. a collision between a train and a road A freight train on route from Areas for improvement that were found mounted boom lift. A container freight Merbein to Dynon derailed eight wagons, during safety audits were: service was travelling from approximately two minutes after departing to and was in the North Geelong – Railway safety audit Mildura Yard on the Melbourne side of the Elders BP/Manor Loop section of the Defined Operators are required to have a system Seventh Street level crossing. Interstate Railway Network (DIRN). The train in place for scheduled audits of their was on the standard gauge line which was PTSV attended the incident and conducted management systems used to determine being fouled by the boom arm of a boom lift. a compliance inspection. the effectiveness of the railway safety The train collided with the boom arm and 1 June 2007: Camberwell train collision system. A number of operators were not the basket of the boom lift, which was being and derailment conforming with their own management used to perform maintenance on a road over During a shunt into the A siding at systems, which require them to conduct rail bridge. The boom lift was located on Camberwell a three-car Comeng (leading scheduled internal rail safety audits. the road surface. The worker in the basket car 632M) collided with a baulk and Corrective actions raised from audits were of the boom lift was seriously injured as a subsequently derailed one wheel of the not being followed in accordance with result of the collision and subsequent fall. leading bogie. There were no injuries their management system requirements. PTSV undertook a compliance inspection and some damage to the baulk. PTSV Worker competencies which resulted in the following safety issues attended the incident and conducted A number of operators did not stipulate being identified: a compliance inspection. minimum competency standards for rail > selection of track force protection 12 June 2007: Kerang rail safety workers, including trainers and > communication and consultation crossing accident assessors. Some operators were not between parties In June 2007, 11 passengers on a V/Line providing the required training by either a > recording of safeworking information. train were killed when a truck collided with registered training organisation or qualified the train at a level crossing north of Kerang. internal trainers. Enforcement action was undertaken by PTSV and the safety issues were PTSV undertook a compliance inspection Inspection and testing satisfactorily addressed. following the incident to check if V/Line was Operators are required to conform to operating in accordance with the Rail Safety standards for maintenance purposes. 29 February 2007: Kororoit Creek Road Act 2006 at the time of the incident. Standards and frequencies for inspection level crossing accident PTSV is working closely with the government and testing in line with these standards Following receipt of a police report of in implementing strategies to improve are not being adhered to by some a fatal motorcycle accident where a rider level crossing safety, particularly with operators. lost control after crossing the train line, PTSV conducted a compliance inspection regard to risk prioritisation of upgrades and Risk & incident management to determine the suitability of the road analysis of incident trends. Review of risk registers were not being surface at the rail crossing. maintained – after incidents and/or audits. Some were not up to date with rail safety legislation requirements including notification requirements and monthly reporting.

20 Key rail issues for 2006-07 Tram squares Variation to V/Line accreditation PTSV has been monitoring tram derailments In May 2007, V/Line was granted a variation at four locations in metropolitan Melbourne to its accreditation to manage the Victorian where trams and suburban trains intersect regional rail network following the state (tram squares). These tram derailments government’s decision to buy back the occur usually as a result of the application network from Pacific National. of equipment designed to derail trams to PTSV worked closely with DOI, V/Line and prevent a tram to train collision. Pacific National to ensure that all necessary The points on the tram side approach to the accreditation requirements were met prior railway level crossing are controlled by the to the hand over of the network. The process railway signaller. Trams can only proceed involved a number of compliance across the level crossing when the railway inspections of V/Line and the previous signaller sets the points to proceed and this Pacific National Network and Access occurs when the crossing is clear. Division to monitor and verify the status of The tram derailer design is a protection transitional arrangements. PTSV will continue method that dates back to the early 1900s to monitor the integration of the regional and the suitability of the system to meet network within V/Line. This new arrangement safety requirements for today’s conditions is is already delivering benefits in terms of a being reviewed. renewed approach to managing the risk to safety of both passenger and freight services PTSV has facilitated the rail and tram on Victoria’s regional rail network. operators in reviewing this technology and carrying out improvements at these Safety approval of Regional Fast sites. Further work is to be carried out, Rail services but PTSV believes the key risks are being The Regional Fast Rail project involved the appropriately addressed. upgrading of the Ballarat, Bendigo, Geelong The tram square locations are: and Latrobe Valley railway lines. This included the delivery of new trains, increased > Glenhuntly Road, Glenhuntly services, the upgrading of track and railway > Glenferrie Road, Kooyong signals as well as capacity for trains to > Burke Road, Gardiner operate at speeds of up to 160 km/h. > Riversdale Road, Riversdale As part of the introduction of these faster services in Victoria, PTSV was responsible for the approval of changes to the accredited safety management systems of the infrastructure manager and rail operator. Changes submitted to PTSV covered areas such as rolling stock, track and structures, level crossings, signalling and operating rules and maintenance standards. Final approval for 160 km/h running was granted in August 2006. PTSV continues to monitor Regional Fast Rail operations.

21 Trains sliding past stations In November 2006, several incidents of In late July 2007 the 25 kph speed trains ‘sliding’ past station platforms restriction on parts of the network were identified by Connex and was lifted to 40 kph following software reported to PTSV as required under rail modifications being made to the safety legislation. Siemens fleet and following PTSV These incidents were limited to Siemens reviewing the test results. The 40 kph trains operated by Connex on the restriction was lifted in late September metropolitan network only. following further evaluation of the performance of Siemens trains. PTSV oversaw Connex’s actions in investigating and rectifying the Siemens The new software has removed some braking issue and ensured that Connex automated braking features and left the risk mitigation actions in place returned greater control to drivers, until a solution to the problem was in line with other trains in the fleet. identified and implemented. Investigations found that the Siemens trains have a greater likelihood of Connex then tested all impounded experiencing overshoots at station Siemens trains and provided PTSV platforms in wet weather. with the test results. Once all safety requirements were met the trains were Investigations revealed that the trains re-introduced to service. had a tendency to experience wheel slip related to low wheel/rail adhesion levels. Working in conjunction with PTSV, When this occurred the train lost its real Connex implemented a number of risk speed reading, resulting in automated mitigating actions which included features of the braking system being the following: activated incorrectly. Siemens trains > a requirement that all Siemens trains consisting of six car configurations have that were returned to service following shown better braking performance than a slide event had to undergo a brake three car configurations and Connex has performance validation test and were agreed with PTSV to maintain six car required with the other Siemens trains configurations for the foreseeable future. to operate as six car sets instead of On 11 October 2007, following ten three car units to assist maximising months of technical investigations, braking capacity the express mode level crossing risk > the immediate notification to PTSV mitigation was lifted. of braking issues > train drivers reducing speed to 25kph PTSV’s first priority throughout this on station approaches (normally driver issue was to ensure the safety of all discretion depending on particular public transport passengers in Victoria circumstances) and continues to closely oversee Connex’s actions to ensure a safe > undertaking safety modifications public transport system at all times. to level crossings to force earlier activation of boom gates (express mode level crossing risk mitigation) > further speed restrictions on approach to curves and junctions and end of the line stations > improved communications with train drivers on changes to procedures. Bus

23 PTSV’s presence in regional Victoria was increased with the appointment of additional bus safety auditors in Bendigo, Benalla and Geelong. Bus audit and compliance activities for 2006-07 A memorable experience during this time was my successful application In 2006-07 PTSV undertook 52 bus safety for funding from the Australian mechanical inspections. In addition, a Qualification Training Framework number of outstanding audits from the (AQTF) to implement a training 2005-06 program were completed. programme for non-English speaking PTSV’s presence in regional Victoria was tram maintenance employees of the increased with the appointment of additional PTC using tactile models of cars bus safety auditors in Bendigo, Benalla and and flags so that trainees could Geelong. New bus accreditation & audit demonstrate their understanding offices were opened in Geelong and Bendigo. to assessors. PTSV intends to recruit three more bus safety The biggest change in the rail and bus personnel for both metropolitan and regional Tricia Brett industries over the years has been areas in the next financial year. Manager Bus Accreditation and Audit the modernisation of approaches to managing safety and the changing In summary, the Bus Accreditation & Audit I’ve worked in public transport for demographics of the workforce, team undertook the following in 2006-07: 29 years, starting out as a tram including more women and young > 961 compliance audits conductress at the Essendon Depot. people joining the industry. Many > approved 60 new accreditations In 1978, two weeks after arriving in women have been involved for a long > renewed 80 accreditations Melbourne from Devon in the United time, but now are coming forward as Kingdom, I began working for the owner-operators rather than being in Melbourne Metropolitan Tramways administrative roles. Board (MMTB) and I’d never seen a tram before. A typical day for me is talking to bus operators about any incidents that may Throughout my career, I’ve been a tram have occurred or safety matters more driver, a depot starter (the person who broadly. Because I am responsible for looks after the operational aspects of the accreditation of as a depot and who takes on management well as bus operators, it is vital that I responsibilities out of office hours) and am across both bus and rail legislation the first female operations controller (particularly the recently introduced (i.e. scheduling trams and handling Rail Safety Act 2006). accident incidents and accidents). When not working on projects, my My current role as Manager Bus team (which is spread throughout Accreditation and Audit really came Victoria) is monitoring accreditation about from my work at the Public issues and ensuring audits are up-to- Transport Corporation in emergency date and all non-compliance reports management in the engineering are closed out. division. This was a coordination and planning role, which then led to occupational health and safety, creating an opportunity for me to study risk management engineering at university. Review of Bus Maintenance Review of Transport Management Course Transport Safety Accreditation Audit and Management System In 2007 PTSV undertook a review of the Reporting System Accredited bus operators are required to Victorian Transport Management Course Transport Safety Accreditation Audit and have a bus maintenance management to ascertain if the course is meeting the Reporting System (TSAARS) is PTSV’s system (MMS). When accreditation was requirements of the Public Transport computer-based application that supports introduced in May 2000 it was agreed with Competition Regulations 1999 and adding the business processes of accreditation the bus industry that a bus maintenance benefit to the Victorian bus industry. including accreditation payments, audit, system developed by VicRoads and the The course is conducted by Monash compliance, and occurrence tracking and Bus Association Victoria would satisfy this University for bus operators and contains reporting. The details of all accredited rail requirement. However, it was agreed that four modules including: and bus organisations are held in TSAARS PTSV would undertake a review of the along with the details of all interactions with > marketing and planning system in the future. these organisations. > finance A review of the bus MMS was completed > human resources Key developments that have occurred over in early 2007. The review found that the 2006-07 include: > legislation and safety introduction of an MMS had improved the > the loading of 30,000 historical notifiable The review concluded that the course met standard of bus maintenance in Victoria. occurrences into the database the criteria set and should continue in its Licensed Bus Testers current form. > operational use of the notifiable Annual bus inspections are conducted occurrence capability to enter both rail and LBT Workshop by 23 independent licensed bus testers bus incidents PTSV in partnership with VicRoads held an (LBTs) authorised by VicRoads. The > automated generation of invoices for LBT Workshop in June 2006. The purpose of annual inspection is a check of all safety annual accreditation payments related systems on the bus and confirms this workshop was to increase awareness that the bus is being maintained to the of training programs, inform LBTs about the > support for multi-site audits, so that required standard. electronic reporting system project and to each facet of the audit can have its own provide an update on VicRoads requirements. independent audit checklist(s). This was PTSV has been working with the LBTs and A majority of the LBTs attended, many particularly important for large rail audits bus industry to improve the efficiency and of them from regional Victoria. Various effectiveness of the annual bus inspection. > the introduction of iTrack Mobile presentations and demonstrations were held The current bus inspection is a paper based – software that supports the audit process including a tour of Dyson’s new maintenance system which has limited the ability of PTSV on a PC independent of the corporate facilities. All who attended hailed the to gather any meaningful data or trends from network, this allows electronic audit workshop as a great success and it was the defects recorded. planning guidelines and checklists to be agreed that these workshops would be used during an audit site visit PTSV has worked with the LBTs to develop held annually. an electronic reporting system (ERS) for > release of a comprehensive user 2006 Bus Industry Maintenance recording the annual bus inspection. guide – available in both paper and Conference The ERS reporting system will enable LBTs electronic format. to transmit daily the data gathered from the PTSV had a stand at the 2006 Bus Industry Three key related initiatives currently under annual bus inspections. Maintenance Conference at Moonee Valley investigation and/or development include: Racecourse in July 2006. This conference The ERS will benefit both the LBTs and PTSV. > the potential for the use of iTrack Direct – was attended by a large number of bus The current inspection process is time- a web based version of TSAARS that operators and is an important part of consuming and requires double data entry is able to access the same physical disseminating information, especially to which contributes to the delay in information TSAARS database regional operators. being provided to PTSV and VicRoads. The > an adaption of the iTrack Mobile software ERS will enable PTSV to analyse the data that operates on a hand held computing to determine whether there are any safety- device, and will allow Licensed Bus Testers adverse trends in the data. ERS is expected to record the details of bus inspections, to be piloted during the first quarter of 2007- and print a resulting bus/defect certificate. 2008 and the results will be reported in next year’s annual review. A pilot is expected to commence in September 2007.

26 Looking ahead

27 The new rail safety legislation offers Victoria’s rail industry a unique opportunity to move to world’s best practice in managing the risks to safety of rail operations. Looking ahead Expectations going forward Train driver route knowledge in a The new rail safety legislation offers multi-operator environment Victoria’s rail industry a unique opportunity The ability to safely pilot a complex to move to world’s best practice in managing multi-joined entity such as a train relies the risks to safety of rail operations. There not only on the technical skills of the train is still much work ahead to embed in full the driver but also his or her appreciation of spirit and letter of the new laws. PTSV will the state and nature of the track the train continue to work collaboratively in bringing will traverse and any safety restrictions about staged compliance with the new laws. in place. In regional Victoria, with some In the forthcoming year PTSV intends to freight lines being only used during times target the following safety critical issues: of bountiful grain harvests, maintaining an adequate supply of train drivers with the Managing catastrophic risk potential requisite route knowledge can become Rail – and particularly the passenger a challenge. Add to this the pressures of rail industry – carries significant an ageing workforce, and maintaining potential for high consequence events this pool of qualified train drivers requires such as derailments or train-to-train careful management. PTSV will be working collisions. While technical safety systems closely with the rail industry in exploring – signalling, train/track protection systems options for meeting this safety challenge. and operator training are designed to control these risks, it tends to be at Achieving excellence in inspection the interfaces where risk defences fail. and maintenance Including safety into every aspect of The Victorian rail and tram network has a rail operator’s activities – from the been built up over the last 150 years and, boardroom to the track and beyond to although regularly maintained, renewed procurement, design and provision of rail and expanded, it requires constant rollingstock and infrastructure to address inspection and maintenance if it is going these interface risks – will be a key theme to continue to operate as safely as is of regulatory action into 2008 and beyond. reasonably practicable. A number of rail incidents and occurrences during 2006- Improving the quality of investigations 07 have indicated that current standards conducted by rail operators of rail maintenance may require review Thorough investigations of adverse to continue to meet the increasing incidents are a vital component of a rail demands on Victoria’s rail network. or bus operator’s management of the In 2007-08 PTSV intends to closely risks to the safety of their operations. By monitor rail safety maintenance and the identifying the real causes of incidents, implementation of improvements in the operators are able to implement positive rail network, particularly in regard to the risk management controls to prevent metropolitan network. similar occurrences in the future. Thorough investigation of incidents Bus safety legislation underpins continuous safety improvement. Currently a review of bus safety legislation Improving operator investigations will be is being undertaken by the Public an area for regulator attention over the Transport Division of DOI. It is anticipated coming year. that this legislation will provide PTSV with similar compliance, enforcement and The Contributing Factors Framework will education responsibilities to those applied provide a nationally consistent, structured to the rail industry. framework and process to record the contributing factors identified during a systemic investigation.

29 Appendices Appendix one Heavy rail safety statistics

Victorian heavy rail safety incident statistics 2003 – 2007

Please note that the term ‘heavy rail’ excludes trams. The following statistics are broken down into six monthly periods. Jan- July- Jan- July- Jan- July- Jan- July- Jan- June 03 Dec 03 June 04 Dec 04 June 05 Dec 05 June 06 Dec 06 June 07 Fatalities 4 6 7 5 5 9 7 7 15 Fatal incidents 4 6 7 3 5 9 6 7 5 Serious injuries 13 17 7 2 12 40 35 77 88 Passenger fatalities 1 0 2 0 0 0 2 1 11 Passenger serious injuries 7 13 6 1 5 23 13 57 59 Fatalities at level crossings (collision with road vehicle) 1 0 1 3 2 3 3 3 11 Fatalities at level crossings (collision with person) 2 0 1 1 2 2 3 1 2 Level crossings (near miss with person or road vehicle) 56 58 64 77 76 82 97 120 133 Derailment 8 9 14 9 15 8 7 14 7 Running line collision 15 26 21 28 29 45 34 33 33 Train/train collision 2 2 1 0 1 2 2 0 1 Signal passed at danger (SPAD) 85 113 93 75 74 76 79 76 93

31 Definitions (heavy rail) Factors impacting on data The Data Collection Quality Project (DCQP) Fatality A number of initiatives and events have is a joint project with industry aimed at A fatality includes the death of employee, impacted on PTSV’s data such that increases improving both the quality and quantity of passenger, trespasser, or member of have been observed over time. occurrence data. As a result of these efforts, it is anticipated that there will be an increase the public (excluding suicides and Effective from 28 January 2003, PTSV natural causes). in reports received by PTSV. Over time, this requested rail operators to report details improved reporting regime may lead to Serious injury of all occurrences. This resulted in ongoing increased numbers of occurrences reported. Serious injury of an employee, passenger, increases in the reporting of occurrences. trespasser, or member of the public Additionally, the implementation of new The significant increase in the number of (excluding suicides and natural causes). legislation in August 2006 changed reporting fatalities can be attributed to the Kerang Please note that from 1 August 2006 the requirements. occurrence. Kerang, along with the change in Rail Safety Regulations 2006 changed the definition, also contributed to the increased As in 2003, this requirement also resulted number of serious injuries. definition of serious injury, such that it in increased reporting and is most apparent includes a person transported to hospital. for the serious injury data. A change in the The new definition impacts on the serious definition of serious injury, in accordance injury figures. with the new legislation, accounts for the Running line collision significant increase in numbers for 2006-07 Collision with train, rollingstock, person, financial year. infrastructure and road vehicle. Excludes Finally, the increase in heavy rail patronage level crossing collision, collision with may have served to amplify the number of animal, obstruction, missile (eg. object occurrences. thrown at train) or other. Level crossing collision Only includes collision with person and road vehicle at a level crossing. Signal passed at danger Where a train passes, without authority, a signal displaying a stop indication or stop aspect. Includes, human error SPADS (driver misjudged, completely missed while running and starting against signal) and signal restored as train approached. Fatal incident An incident where at least one fatality (excluding suicides and natural causes) has occurred.

32 Appendix two Tram safety statistics

Victorian tram safety incident statistics 2003 – 2007 Jan- July- Jan- July- Jan- July- Jan- July- Jan- June 03 Dec 03 June 04 Dec 04 June 05 Dec 05 June 06 Dec 06 June 07 Fatalities 0 1 1 1 1 1 0 0 0 Serious injuries 29 30 14 30 18 4 5 4 5 Running line derailment 34 30 28 24 43 27 14 16 11 Tram/tram collision 14 9 9 9 11 18 10 6 12

Definitions (tram) Running line derailment Fatality Any derailment occurring in the A fatality includes the death of an movement of a tram on a running line. employee, passenger, trespasser, or Tram/tram collision member of the public (excluding suicides Any running line collision between and natural causes). two or more trams (excludes level Serious injury crossing collisions). Serious injury of an employee, passenger, trespasser, or member of the public (excluding suicides and natural causes). Please note that from 1 August 2006 the Rail Safety Regulations 2006 changed the definition of serious injury, such that it includes a person transported to hospital. The new definition impacts on the serious injury figures.

33 Appendix three Bus safety statistics As a condition of accreditation, bus operators Bus passenger fatalities are required to advise PTSV of any bus safety incidents that occur when operating across 2003 2004 2005 2006 As at 30 Victoria. The tables below show fatalities, Jun 2007 serious injuries and collisions from 2003 to 1 the end of June 2007.

Analysis Bus passenger serious injury Bus passenger fatalities 2003 2004 2005 2006 As at 30 Over time, the number of bus passenger Jun 2007 fatalities remains stable. The one 25 34 70 15 24 passenger death for 2007 occurred on the 31 March 2007 on the Midland Highway. The passenger who was killed was wearing Bus-related fatalities a seat belt at the time of the accident. 2003 2004 2005 2006 As at 30 Jun 2007 Bus passenger serious injuries Accident near bus 1 1 Bus passenger serious injuries show little variation except for 2005. In 2005 there were many more bus collisions with cars and Bus many of these collisions resulted in multiple Car 1 3 2 serious injuries. These two factors also serve Cyclist 1 2 to explain the large number of bus-related Pedestrian 2 3 1 2 serious injury numbers. Train / Tram Bus-related fatalities Truck As can be seen from the table, bus-related fatalities continue to be lower than the 2004 high of seven. This is an encouraging result. Bus-related serious injury Bus-related serious injuries. 2003 2004 2005 2006 As at 30 Jun 2007 Bus-related serious injuries continue to be significantly lower than the high of 58 in Accident near bus 2 2 1 2 2005. As noted above the high number of Bus collisions with cars and the multiple injuries Car 16 4 43 7 9 associated with the collisions accounts for Cyclist 1 1 2 1 the high 2005 results. Pedestrian 4 6 7 5 5 Bus collisions Train / Tram 7 7 There has been a significant decline since Truck 4 3 5 2 2005 in the total number of bus collisions, in particular, collisions with cars. Bus collisions 2003 2004 2005 2006 As at 30 Jun 2007 Accident near bus 3 4 1 2 1 Bus 3 Car 27 25 33 23 20 Cyclist 2 6 2 1 1 Pedestrian 8 9 9 7 5 Train / Tram 2 1 2 Truck 7 4 6 1 4

34 Appendix four Appendix five Significant train/tram/bus incidents Improvement notices issued 2006-07 Safety issues covered by these improvement Date Location Description notices include: 12/10/06 Traralgon Derailment of locomotive and passenger train, > notification of safety incidents (2) 11 kilometres east of Traralgon. > safe-working/safe-operating 12/11/06 Winchelsea Level crossing collision between passenger train procedures (2) and utility. > health & safety code (1) > maintenance/engineering standards (4) 12/12/06 Werribee (Bus) A passenger seated on a three wheeled mobility device sustained an injury to the head > safe-working environment/safety critical when the device fell over during the bus’s transit. infrastructure (3) > safety information (1) 18/02/07 Springvale Passenger train overshot Springvale station by three carriage lengths into a level crossing. Eleven of the improvement notices have Level crossing protection was activated at the time. been addressed by the relevant operators and the improvement notices closed. The 1/03/07 City (Tram) Collision between two trams at the corner two remaining safety issues are being of Spencer and Bourke Streets. actioned by the rail operator with an agreed 12/04/07 Healesville Level crossing collision between rail trolley and car completion date of 1 May 2008. at an occupation crossing. 3/05/07 Oakleigh Suburban passenger train derailment approaching Oakleigh Station 4/06/07 Seymour Derailment of a passenger train approaching Seymour Station. 05/06/07 Kerang Level crossing collision between a passenger train and a truck.

35 Appendix six Output performance measures Major outputs/deliverables Unit of 2006-2007 2006-2007 The following section provides details of performance measures Measure Target Actual the outputs provided to government during 2006-07. Quantity Train and tram safety Public transport safety and regulation compliance inspections per cent 100 99 Work with industry stakeholders to achieve Bus safety mechanical inspections number 50 52 the highest standards of safety practicable for train, tram and bus services in Victoria Quality and implement initiatives to achieve the Train and tram safety Government’s public transport safety Improvement Notices addressed objectives. Monitor compliance of public within agreed timeframes per cent 100 100 transport safety management systems Audit non-conformance/ through rigorous audits and inspections, compliance addressed within investigate accidents and incidents, and agreed timeframes per cent 100 741 implement corrective actions. Application for a material change (to a safety management system of an accredited rail organisation) reviewed within 30 days2 per cent 100 100 Bus safety Audit non-conformance/ compliance addressed within agreed timeframes per cent 100 723 Timeliness Train and tram safety All accredited organisations audited annually4 per cent 100 100 Bus safety All accredited organisations audited every two years5 per cent 50.0 52.2

1 As of 1 August 2006 the new Rail Safety Act came into effect resulting in changes to the safety audit framework, including changes to the monitoring and reporting of compliance and audit activities. The implementation of new legislation involved some lead time for full recruitment and training functions to be fully implemented. 2 An accredited rail operator means a rail infrastructure manager or rolling stock operator who is accredited under Part 5 of the Rail Safety Act 2006. There are 45 such operators in Victoria. 3 Bus operators have not responded to 28 percent of non-conformance/compliance within the designated timeframe. Action is being currently undertaken to pursue the issue with bus operators. 4 Refer to footnote 2. 5 The Public Transport Competition Act 1995 requires operators of vehicles with more than 12 seating positions (including the driver) that are used to carry passengers for other than domestic purposes to be accredited. There are approximately 1,600 operators in Victoria.

36 Data sources for industry statistics Page 8 Patronage statistics from DOI 2006-07 Annual Report. Page 13 Labour Force statistics from Australian Bureau of Statistics, Labour Force Projections, Australia, October 1999. Page 31 Heavy rail, tram and bus statistics – PTSV Occurrence Database, data as reported to PTSV from Accredited Operators.

If you would like to receive this publication in an accessible format, please telephone Suzanne Waddell on 9655 2050, or email [email protected]. This publication is also published in PDF on www.ptsv.vic.gov.au. Published by Public Transport Safety Victoria Level 8, 121 Exhibition Street, Melbourne, Victoria 3000 Telephone (03) 9655 8949. November 2007. Copyright State Government of Victoria 2007. This publication is copyright. No part may be reproduced by any process except in accordance with provisions of the Copyright Act 1968. Authorised by the Victorian Government, Melbourne. ISSN: 1835-4262

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

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