Derailments, signals passed at danger, level crossings incidents, and track workers coming into conflict or potential conflict with trains represent serious concerns to the rail industry.
Though potentially devastating, every accident presents a new opportunity to refine safety protocols and amplify safety messaging to minimise the likelihood of a reoccurrence.
The Australian Transport Safety Bureau (ATSB) has a long history of no-blame independent accident investigation across the marine and aviation transport modes. The ATSB’s expanded role in rail is more recent, but the Bureau has already made a significant contribution to improving safety for the industry.
Ahead of the RISSB Rail Safety Conference, we spoke with the Bureau’s Executive Director, Transport Safety, Mr Nat Nagy, to gain some insights into the key safety learnings that have been discovered by the ATSB’s work to date.
What are some of the ‘major safety offenders’ in rail?
A major focus of ours is safe work on track. Every track worker has the right to work in a safe workplace environment.
There are a number of rules and procedures already in place to protect track workers, but occasionally human or technical issues can compromise existing safety practices.
Simple things like a communication breakdown between a network control officer and the site protection officer can have serious consequences.
It is our role to find out why these rules and procedures have been compromised, and then amplify safety messaging throughout the rail industry to influence change.
What sets you apart from other investigators like the ONRSR, police, coroner, insurer, or track owner?
When an accident occurs, a number of agencies may be involved – with different objectives – to determine what happened and why.
The ATSB investigates ‘what’ happened and then, more importantly, determines ‘why’ it happened from a systemic and operational point of view.
We are not the regulator and we do not have the ability to enforce change. However, we can make safety recommendations to all organisations.
Our investigations look to discover any systemic safety issues, allowing us to publish critical safety messaging to influence change. And we do this without apportioning any blame – prosecution is not within our remit.
As an example, our investigation into the derailment of a freight train at Julia Creek in December 2015 identified the need for the implementation of procedures and training programs to ensure the timely identification and management of hazards, such as a weather event, that may adversely affect the integrity of rail infrastructure.
When we do identify a critical safety finding, we will notify the rail community and amplify that safety message immediately, without waiting for a report to be finalised. We see this as core to our mission of improving transport safety for the travelling public.
Who or what informs your investigative work?
Our investigative work can involve walking the track, sifting through wreckage, interviewing operators and witnesses, and analysing a broad range of recorded data.
Data is particularly important to us. In certain circumstances, data might be the only evidence we have beyond badly damaged wreckage, which may not yield much information.
Beyond train data loggers, typically there are cameras on most platforms and level crossings, and sometimes passengers themselves are often filming when accidents occur.
We gather data from a range of sources and then use this information, along with other forms of evidence, to create a clear picture of what happened. Then, we focus our attention on investigating why the event happened.
Combined, these data sources allow us to produce an animation of an incident if required. In conjunction with a written report, an animation is a valuable resource for industry to help learn from the occurrence.
In the coming years we anticipate our data analysis capabilities will continue to develop, particularly with the rise of automation in transport. Where there’s automation there will be a plethora of data, should we need it.
Mr Nagy will be available at the RISSB Rail Safety Conference – due to take place 2-3 April 2019 in Melbourne.