
ATR Seminar 2006
Accident / Incident Notifications & Investigations
ARO Reporting Obligations
Rail Safety Regulations
Part 6
Definitions railway accident or incident:
an accident or incident on railway premises that results in:
The death of a person;
Serious injury to a person resulting in that person requiring immediate medical treatment by a registered medical practitioner with in in the meaning of the Medical Practice Act 1994;
A running line derailment of any unit of rolling stock;
A collision between any rolling stock and any person;
A collision between any rolling stock and any other vehicle, infrastructure, obstruction or object which resulted in significant property damage;
An implosion, explosion, fire or other occurrence which resulted in significant property damage;
A notifiable accident or incident.
Notifiable accident or incident
A railway accident or incident which the Safety Director has specified under regulation 42(1)
Notifiable circumstances
A circumstance, act or omission that resulted in, or had the potential to result in, the death or serious injury to any person, or significant damage to property and includes:
Any defect in, or failure of, any part of the rail infrastructure;
Any defect in, or failure of, any rolling stock or part of any rolling stock;
Any failure or breach of any rail operations practice, procedure or rule;
Any other
circumstance, act or omission that the Safety Director has specified under
regulation 42(2) to be a notifiable circumstances.
Note: The Safety Director may specify an accident or incident notifiable circumstances to be notifiable.
Railway accidents or incidents
Any ARO must notify the Safety Director immediately after becoming aware that a railway accident or incident has occurred.
Within 72 hours
give the Safety Director a record of the railway accident or incident in an
approved form.
Note Safety Director may extend this time in writing.
Notifiable circumstances
An ARO must notify the Safety Director in writing of a notifiable circumstance that has occurred in relation to the rail operations for which the operator is accredited.
Reports
Investigations
Section 67 of Rail Safety Act 2006
Regulation 45 of Rail Safety Regulations 2006
Report to be prepared containing the information under sub-regulation (3)
Copy of reports must be provided to Safety Director as soon as practicable after completion.
ARO may be required to:
Conduct a more detailed investigation
Provide further information
Clarify certain matters contained in the report
ARO have 7 days to comply with the above
Monthly Reports (Regulation 46)
A rail operator must for each calendar month give the Safety Director a report, in an approved manner detailing:
Total number of rail workers in the month
Total number of pax journeys in the month
Total number of track kilometres
Total number of pax train kilometres
Total number of freight train kilometres
Report required within 10 days of end of the previous month
The Safety Director may allow (b) above to be provide every 3 months
Note: Compliance with this Regulation is a condition of accreditation
Tourist & Heritage railways operators may apply to the Safety Director for an exemption from the requirement to submit a monthly report.
Note: You may have other occurrence reporting requirements Workcover etc.
Duty to preserve accident or incident site (Regulation 48)
Accidents or incident notified under Regulation 43
Site can not be disturbed until directed by:
A transport safety officer The Safety Director
except
To protect the health or safety of a person; or
Aiding an injured person involved in a railway accident or incident; or
Taking action to make the site safe or to prevent a further occurrence of accident or incident; or
Allowing emergency services to manage the emergency
Investigations
Who can conduct a rail investigation in Victoria:
Commonwealth ATSB DIRN Safety Director (PTSV) Rail Safety Act 2006 (section 228ZB)
Victorian Chief Investigator, Transport and Marine Safety Investigations & Transport Legislation (Safety Investigations) Act 2006
Victorian Police
Victorian Coroner
Conducting an Investigation
References: AS4292.7
ARA CMC (Australia Code of Practice Man 6-2 (Ver 1.0)
Rail Safety Investigation
Why investigate
To determine what happened
To determine how it happened
To determine when it happened
To determine why it happened
Why a Code of Practice
Provides procedure tools and examples to assist AROs in the conduct of an investigation
The Code complies with the intent of AS4292.7
Provides a structured systematic, consistent approach to investigation
Focuses on systematic contributors to the occurrence
What does AS4292.7 require?
Necessary steps be taken to preserve evidence Occurrence needs to be reported:
IAW with procedures; and
Legislation The responsible authority (In the ARO) must be notified
The severity of the occurrence assessed:
Appropriate level of investigation undertaken
An investigator appoint and TORs prepared
A final report produced
Code of Practice Theoretical Framework
The Core Principles: Systems approach
Just Culture philosophy
Commitment to learning from failure
A structured systemic and iterative process for gathering and analysing data
Development of non-prescriptive recommendations
Management to fair and independent investigation
A
Systems Approach
Occurrences not normally one off events/isolated Almost always symptomatic of broader organisational issues
Need to investigate beyond immediate events
What else contributed to the event
Significant organisation accidents
Three Mile Island SUA March 79
Human error
Design deficiencies
Component failures
Chernaby
Herald of Free Enterprise
Londons Kings Cross Fire
Clapton Junction Train Collision
Waterfall in NSW
Organisation are Systems
A system is an assemblage / contribution of things or parts forming a complex or unitary whole Systems are made up of:
People
Business, work processes, management frameworks
Technology tools, equipment
Physical and non-mode environment
The Reason Model
Developed by Prof James Reason late 1980s/early 90s After research into accidents several industry
Resulted in a simple explanation of key characteristics of an organisational accident
Human Error
Error is inevitable
But focus is often on the sharp end only
Errors occur throughout organisations
By people often remote from the operation
Active Failures
Made by operational staff
Latent Failures
Systems/organisational failures
Made by executives, designers, etc
Organisation Model
Contributing Factors
Organisation Factors The management input:
Decision making, training, contractor management
Workplace (local conditions)
Psychological condition of people involved
Task/environment characteristics/conditions
Knowledge/skills
Individual and/or team actions
The active failures
Errors
A planned sequence of mental or physical activities fails to achieve its intended outcome
Violations (intentional non-compliance)
Technical failures
Items that dont come from operator error
Broken rail
O ring failure in the Challenger space shuttle (1986)
Just Culture
Human error is a normal consequence of human activity Just culture
Is transparent and establishes clear accountability for actions
It is not punitive or blame free
Learning Organisation
Dont waste the accident/incident
The Investigation Process
Level of Investigation
Events and Conditions Chart
Exercise - Berrburrum
Prepare an Events and Conditions Chart
Prepare an Organisational Error Chart