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.

 

     Duty to Notify

     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

 

Exemptions (from Regulation 46)

•      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

 

  • Importantly – To prevent similar events repeating

 

Why a Code of Practice

•      Provides procedure tools and examples to assist ARO’s 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 TOR’s 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

–     London’s 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 1980’s/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 don’t 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

–     Don’t ‘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