railway – Page 5 – SafetyAtWorkBlog

Compensation denied because police officers only saw the aftermath of fatal incident

In 2003, emergency responders attended a major rail incident at Waterfall in New South Wales, in which multiple passengers were injured and seven died. According to a 14 April 2010 article in The Australian (page 7, not yet(?) available online):

“The officers [David Wicks and Philip Sheehan] were among the first at the scene of the crash that killed seven people, including the driver, who lost control of the train after he had a heart attack”.

Those officers have been denied compensation under the NSW Civil Liability Act because

“they did not witness the crash, only its aftermath.”

Both police officers had been diagnosed with post-traumatic stress disorder (PTSD) and been medically discharged.

Their claim for compensation has now reached the High Court of Australia Continue reading “Compensation denied because police officers only saw the aftermath of fatal incident”

Government can do much better on level crossing safety

The Victorian Government is likely to say the Auditor-General’s report into “Management of Safety Risks at Level Crossings“, released on 24 March 2010, supports the government’s initiatives. This is true but the report says much more than just describing the State Government’s efforts as “satisfactory”. (If my child’s report card said satisfactory, I would be talking to the teacher about why the performance was only “satisfactory”)

The report summary says the following:

“The rate of progress in improving safety and reducing accidents has been satisfactory. There are, however, elements of the risk management framework and its application that can be improved.”

These elements are specified as

“improving how the committee is informed of the views of the rail managers, who run train services and maintain the infrastructure, about their risks and priorities

assembling information that will allow the committee to effectively manage and monitor the delivery of the Towards Zero strategy

improving the understanding of what causes level crossing collisions.” [link added]

Clearly the Parliamentary committee is not getting the full risk story from the rail managers. Continue reading “Government can do much better on level crossing safety”

Level crossing investigation reports

The Victorian Auditor-General is conducting an investigation into the “management of safety risks at level crossings”. Victoria’s Coroner is also investigating several, of the many, deaths at level crossings.

According to the Auditor-General’s website the level crossing report will be tabled in Parliament next month. It is understood that the three nominated level crossing hearings of the Victorian Coroner will commence sometime in 2010. Continue reading “Level crossing investigation reports”

John Holland prosecution

The John Holland Group has featured several times in the SafetyAtWorkBlog in 2009. Any organisation as large as this Australian conglomerate who promotes their commitment to safety and whose Board Chair, Janet Holmes a Court, has such a high profile is going to draw media scrutiny. In fact, the evolution of the John Holland safety culture and the struggle to maintain such a culture as a company grows in profitability and complexity would make a fascinating case study.

On 18 December 2009, Comcare released details of its latest successful prosecution of John Holland. This time the company was fined $A180,000 over the death of a worker, Mark McCallum, at the Dalrymple Bay Coal Terminal in Queensland in May 2008. According to the media statement:

“Justice Collier stated that “It is clear that, despite the efforts taken by the respondent to implement a safe working environment, the operation involving the transportation unit was flawed in its original conception. The dangers were obvious from the start, relatively simple to avoid, but unrecognised and unaddressed in a manner which raises the objective gravity of the offence in these proceedings towards the higher end of the scale.” [emphasis added]

When a judge determines that the process was flawed from the very start, one’s expertise in managing an established practice safely should be critically reviewed. Such fundamental failures in a safety management system should cause any company to realise something is wrong in the way it is addressing safety needs, particularly in an economic climate that is bursting with new infrastructure projects for which one is competing.

The circumstances of the fatality are that

“A team of five John Holland workers were involved in moving large precast concrete decks to the end of a jetty under construction. The precast concrete decks were being transported on two jinkers that were being pushed by a front end loader. During this procedure, a worker’s foot became trapped under wooden scaffolding planks on the jetty, and he was fatally injured when he was run over by the wheels of the jinker.”

The Federal Court judgement listed the safety deficiencies that John Holland acknowledged

“The respondent acknowledges that:

(a) its work method statement did not adequately identify the risks associated with the relevant work process, and did not adequately identify suitable control measures to remove or minimise those risks; and

(b) it did not carry out a plant hazard assessment with respect to the front and rear jinkers, which may have identified a requirement for a remote braking system or other controls on the jinkers for use by spotters and others; and

(c) it did not have in place a formal system whereby employees were certified as being competent in the use of jinkers; and

(d) it did not have in place a formal protocol or procedure for the use of radios to ensure that the transmitter of a radio message was able to be informed that the message had been received by its intended recipient and understood; and

(e) it did not have sufficient communication mechanisms in place to ensure that employees working out of sight of the loader operator and the rear spotter were able to communicate directly with spotters and the loader operator; and

(f) it did not ensure that an observer of a trainee jinker operator was also issued with a radio to directly communicate with the other members of the transportation crew responsible for the propulsion of the load; and

(g) it did not provide workers who were working out of sight of the loader operator or rear spotter with any form of alarm or safety device, other than a radio to alert other workers of the occurrence of an emergency situation; and

(h) it did not ensure that the clearance of obstacles in the path of the loader was done in a timely or effective manner, thereby requiring the front jinker operator to perform that duty during the progress of the transportation unit and whilst out of the line of sight of the loader operator.”

Mark McCallum’s death gained even greater media attention when unions challenged John Holland’s nomination for a safety award shortly after McCallum’s death.

Kevin Jones

Big fine for Queensland Rail – big risks in rail

Almost two years ago, two rail workers died in Queensland. According to the official report into the incident:

“At approximately 1056 on Friday 7 December 2007, two QR [Queensland Rail] Infrastructure Services Group (ISG) track workers were fatally injured as a consequence of being struck by a track machine (train) at Mindi, approximately 130 kilometres south-west of Mackay.

The collision occurred when Track Machine MMA59, in the process of conducting track resurfacing work on the Down line at Mindi, commenced a routine reversing movement.

During the process, two QR Systems Maintenance personnel, working on the same track and behind the track machine, were struck and fatally injured by this track machine.

Analysis of evidence and conditions surrounding the accident revealed:

An overall lack of compliance with elements of the QR SMS at the Mindi site; and

Inadequate communication and coordination between workgroups at the Mindi site.”

On 26 November 2009, Queensland Rail was fined $A650,000 over the deaths. The fine is only $A100,000 below the maximum fine applicable. According to a media release about the fine:

“The Workplace Health and Safety Queensland investigation found that QR’s safety management systems were inadequate for managing the separation of workers and plant, particularly when both were within the same section of track between signals.

It also found that QR knew the systems were inadequate and not working because it had been highlighted to management in a series of audits.”

Not only were Queensland Rail’s safety management systems inadequate, Queensland Rail knew they were inadequate because a series of audits had told it so.

Railway in Australia and elsewhere is one of the most regulated industries. It is also one of the industries with the most prescriptive set of rules. It is a complicated business but one where hazards are known and systems are in place to control these hazards.

The extent of QR’s failure to operate safely can be illustrated by some of the many recommendations made in 2008 by Queensland Transport:

The necessity for consistent and effective Worksite Safety Briefings by ISG personnel;

Preconditions to the reversal of vehicles in accordance with QR safeworking requirements;

Responsibilities and training syllabi for ISG Resurfacing personnel;

The necessity for pre-departure safety checks on ISG trains;

Provision of safe separation and segregation between ISG track workers and trains;

ISG SMS compliance monitoring, at the local level;

Fatigue management within QR, and in particular ISG rostering;

Management of the perceived relationship between ISG and Network Control;

Awareness of the priority of safety over commercial pressures by remote ISG staff;

Distribution of safety communications and documents within QR;

Representation for relevant stakeholders in operational change management processes;

Risk and change management training for ISG operational personnel;

Safety risks presented to ISG through the permanent coupling of track machines;

The safety value to QR of an enhanced and transparent reporting system;

The management of ISG district staff relationship issues; and

ISG and Network Access radio protocol compliance monitoring.

Many elements are familiar to other investigations in rail and other industries – fatigue, on-site communication, training, segregation, document control and distribution, local compliance enforcement, transparency in reporting…..

On 10 September 2008, the QR CEO Lance Hockridge said:

“When I arrived in November 2007, I found an organisation with a safety record that was improving but not what it should be. Only three weeks later we had a very tragic reminder of this when work colleagues Jamie Adams and Gary Watkins were killed at Mindi.

“Organisations hoping to achieve meaningful change must firstly be honest with themselves – we need to confront this reality and make the changes required.”

Queensland Rail did not face the reality of problems identified by safety auditors and two workers died.

The news of the record fine came at a time when the ownership of Victoria’s metropolitan rail network has changed from Connex to Metro. Victoria has a stressed rail service but has managed to avoid the controversy of Queensland Rail and RailCorp in New South Wales but this has been through luck rather than good management. The Victorian Government, and particularly the Transport Minister, Lynne Kosky, needs to read the Waterfall Inquiry report and the Queensland Mindi report to understand the personal, economic and political cost of not having a tightly managed, functional rail safety regime. Having been in power for just over 10 years, this government now owns all the Victorian problems and must account to the electorate for not fixing them.

The political risk was summarized in an editorial in The Age on 30 November 2009

“In September, a Senate report into federal funding of public transport found Melbourne’s network was badly managed in comparison with Perth’s government-operated system. A key problem was lack of accountability: it was unclear who was in charge. The consequences of the lack of an overarching transit authority to oversee the whole system are clear…..

New operators of trains and trams in new livery will struggle to deliver acceptable service unless the Government makes good its past neglect of infrastructure.”

The fact that the Victorian rail system is being privately operated will not be an acceptable shield when the first passenger train crashes with a jam-packed peak hour cargo.

Kevin Jones

This may not work for OHS but why not?

On 9 November 2009 public submissions close on Australia’s model OHS Act but the move for harmonisation and, hopefully, a simplification for business and government continues in other areas.

The Australian Transport Council (ATC) met on 6 November 2009 and agreed on many Council of Australian Governments (COAG) matters concerning unnecessary bureaucratic duplication:

“ATC agreed to recommend to COAG that South Australia would be the host jurisdiction for the national rail safety regulator.

ATC also agreed to recommend to COAG that a host jurisdiction for the national heavy vehicle regulator be agreed, noting that New South Wales, Victoria and Queensland have expressed interest.

It was agreed that the Australian Maritime Safety Authority will be the national regulator for maritime safety, responsible for regulating commercial vessels. This is a significant step towards national uniformity.”

There were several other initiatives mentioned – level crossing safety, a National Road Safety Council, minimum standard for taxi drivers.

But the recommendations above decentralise some of the bureaucracy. At the HR Leaders Awards recently, the CEO of Carnival cruise liners, Anne Cherry, said that many public servants exist in a unique policy environment of the capital city, Canberra, and the policies reflect this.

SafetyAtWorkBlog would like to suggest a change that could occur within the enforcement parameters of the OHS model law review.

Let’s consider a national mine safety regulator with offices located in each of the mineral resources regions of Australia. Could transport regulators have offices within, or just outside, major port facilities? Major hazards regulators in major hazards zones?

There is much information bandied around about flexible working arrangements and the use of new technology to unite isolated workplaces. How radical would it be to split the centralised OHS regulators’ offices into hazard-based offices in rural, regional and suburban locations? The inspectors would be adjacent to the hazard locations for enforcement and the advisers are on hand for assistance to industry. The locations could even be seasonal to deal with seasonal industries and labour forces.

OHS enforcement policies would remain the same, only the place of implementation and coordination would change.

Most OHS regulators already have a a couple of regional offices but mostly these remain in the outer suburbs of the capital cities. Some entire departments have relocated to satellite towns for cost reasons but also to provide employment opportunities outside the major population centres.

Could OHS be regulated and enforced across a country the size of Australia and through the major industrial and resource structures, without the concentrations of policy-makers and inspectors in city offices?

Kevin Jones

Level crossings and safety management

Regular readers will know that SafetyAWorkBlog believes that there is little justification for road/rail crossings, particularly in metropolitan areas, and that grade separation should be the aim of any crossing upgrades. Too often governments dismiss grade separation without serious consideration because it is usually the most expensive control option. Regardless of expense, elimination of hazards must be considered in public safety policy and OHS. It is only after the elimination of a hazard is seriously considered that lower order control measures are seen to be valid.

At the moment in Victoria, there is community outrage because the truck driver involved in the deaths of 11 train passengers at a level crossing at Kerang has been cleared of any legal responsibility for the deaths. Several relatives of victims are pursuing civil action against the driver, Mr Christiaan Scholl.

The wisdom of civil action against the driver is debatable as any potential financial “win” will come from the insurance pockets of the Transport Accident Commission and not Mr Scholl. Compensation may be gained but any hope that the action could be seen as a “penalty” is false.

The Kerang rail crossing illustrates some basic OHS issues:

Worker responsibility

The Kerang level crossing had design deficiencies that had repeatedly identified by a number of government authorities, local companies and the public. The court case heard that the crossing was known to be dangerous.

In OHS, known hazards are controlled in a number of ways. Clearly the rail and road traffic was not separated and engineering controls were not introduced at the time of the incident. The owners of the crossing (and this is debated also) determined that signage was appropriate (or even perhaps “as far as is reasonably practicable”?).

Clearly signage was not adequate but there is also the issue of driver (worker) responsibility. It was mentioned in court and repeatedly in the media that the level crossing was known to be dangerous. Why then, would drivers continue to treat the crossing as if it was not? The legal speed limits remained at 100kph, at the time of the incident. The road laws clearly state that road traffic must give way to rail traffic and yet drivers have admitted to complacency.

This is perhaps the source of a lot of the community outrage in relation to the Kerang incident. The findings in favour of the driver place all the responsibility for the incident on the inadequate design of the crossing.

Working environment

As employers have responsibility to ensure a safe and health work environment, so government has a social and legal obligation to make public areas safe. Victorian governments for decades have neglected the hazards presented by inadequately designed or controlled level crossings. Governments must take responsibility for inaction just as much as taking credit for action and infrastructure improvements.

Infrastructure spending had started to increase prior to the incident but the need was sharply illustrated through the unnecessary deaths of 11 rail passengers. Many Australian governments are spending millions of dollars on rail/road crossing upgrades as a result of the Kerang incident.

Road Safety and OHS

Many OHS professionals illustrate OHS by drawing on road safety. The correlation is very poor but the attempt is understandable – most people drive, they drive within strict laws that were learnt in training (induction), and the road laws are enforced by an external body (police = WorkSafe. However, this relationship has no corresponding role for employers, who have a workplace responsibility. The road user has a direct relationship with the regulator. In OHS the role of the employer is crucial.

Perhaps the Kerang incident and other level crossing incidents could be used in brainstorming to illustrate personal accountability, employer accountability and government responsibility. It would be a worthwhile exercise to discuss whether road safety and workplace safety could share as many educative elements as some of the advocates suggest.

As with most posts on SafetyAtWorkBlog, these thoughts are a work-in-progress and debate and commentary are welcome.

Kevin Jones

Note: SafetyAtWorkBlog is not privy to any of the court evidence and must rely on media reports. More information will be presented when available.

Category: railway

Compensation denied because police officers only saw the aftermath of fatal incident

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Government can do much better on level crossing safety

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Level crossing investigation reports

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John Holland prosecution

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Big fine for Queensland Rail – big risks in rail

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This may not work for OHS but why not?

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Level crossings and safety management

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