transport – Page 41 – SafetyAtWorkBlog

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

Quad Bikes – industry response

On 30 November 2009, the CEO of The Federal Chamber of Automotive Industries, Andrew McKellar, responded to some of the issues raised in recent SafetyAtWorkBlog articles concerning the safety of quad bikes.

McKellar emphasised that a balanced approach to ATV safety discussions is required. He said:

“In terms of a statistical outcome, the results show that, on balance, [ROPS] does not result in a safer outcome, in some situations people are going to be killed where otherwise they would have been fine. In other circumstances, they will survive an accident or a rollover accident where they might have been seriously injured if they hadn’t had it…….There is no clear safety benefit from putting such structures on those vehicles.”

As has been shown in previous articles many Australian and New Zealand OHS regulators have not recommended ROPS for quad bikes. This indicates that there must be some convincing evidence that ROPS are inappropriate. But that leaves the same problem with quad bikes in 2009 that existed decades ago, people are becoming injured or are dying from the (mis)use of these vehicles.

In most other vehicle and manufacturing circumstances consistent misuse would indicate that the vehicle itself and the interaction between driver and vehicle requires considerable investigation and/or redesign. The investigation by Ralph Nader was referred to in an earlier article as an example of unsafe design being engineered out.

Equipment designers in a range of industries strive to make their equipment foolproof but there does not seem to be same motivation in the quad bike manufacturing industry which still advocates helmets as the best hazard control option. This option is supported by calls for safe driving courses and keeping within the manufacturers’ specifications.

Helmets may be best practice at the moment but it is hard to believe that that is where the situation should stay. By not progressing beyond this control option, manufacturers and safety regulators are focusing on rider awareness in a sector, agriculture, that is renowned for taking (inventive) shortcuts and whose principal workforce are men who have a macho dismissive attitude to safety. A new approach is required.

Kevin Jones

Australian research figures into quad-bike deaths and injuries

A SafetyAtWorkBlog reader drew our attention to a research report on quad bike safety by one of Australia’s most well-known researchers into agricultural safety, Lyn Fragar.

The report entitled “ATV Injury on Australian Farms – The Facts – 2006” details a compilation of police, hospital and injury data from many years concerning ATVs or quad bikes. Recommendations and observations are made but curiously the design of the vehicles is not considered as a contributory factor in rollovers and rollover protection structures are not mentioned.

Kevin Jones

Further quad bike safety information

In January 2003, the Federal Chamber of Automotive Industries (FCAI) issued the following media statement outlining its initiatives to reduce the injuries associated with quad bikes on farms in Australia.

SafetyAtWorkBlog is following up with the FCAI for further information on quad bike safety and any objections the FCAI has to roll-over protection structures. An earlier article on quad bike safety is available HERE.

“The peak industry body representing the major motorcycle and All Terrain Vehicle (ATV) distributors has reinforced its support for on-going safety campaigns to help reduce ATV accidents.

The FCAI Motorcycle Group is concerned that a number of recent ATV accidents may have been the result of overloading or a lack of understanding of ATV operation.

The FCAI strongly recommends ATV operators should adhere to the following safety measures based on ATV manufacturers’ instructions:

always wear a helmet

do not carry passengers

do not exceed recommended maximum load and towing capacities

comply with the manufacturer’s recommended minimum user age for the vehicle

never operate an ATV under the influence of alcohol or drugs

follow the manufacturer’s maintenance procedures

The FCAI advises ATV operators who do not have a copy of the manufacturer’s instructions to seek a replacement from their nearest dealer.

The FCAI said recognising the risks associated with overloading an ATV and the dangers of carrying a passenger could significantly reduce ATV accidents.

“Appropriate speed for conditions and avoidance of riding on steep slopes could also further reduce ATV accidents,” said Mr Peter Sturrock, chief executive of the Federal Chamber of Automotive Industries.

An average of 10,000 ATVs have been imported annually into Australia over the past five years, according to figures from the Federal Chamber of Automotive Industries.

“Some ATVs are designed for competition and recreational riding but the greater majority of ATVs imported to Australia are agricultural ATVs sold directly to the farming sector,” Peter Sturrock added.

The FCAI Motorcycle Group has been actively involved in the promotion of ATV safety to consumers since 1997.

The Group committed $25,000 production costs to the first edition of a safety video “You and Your ATV” in 1998.

The video focuses on safe and responsible riding practices for ATVs and includes safe loading and securing methods.

More than 35,000 copies have been distributed free to ATV purchasers and owners.

The FCAI Motorcycle Group allocated $29,000 in 2002 to a second edition of the video.

The Group also provided expert advice and assistance to the development of an ATV Training Course for TAFE farm students.

The FCAI has also provided the services of its Motorcycle Manager Ray Newland to attend meetings of state and federal WorkCover Authorities for examination and progress of ATV safety issues.

In November of last year, the FCAI conducted a ‘field day’ for key national stakeholders involved with ATV safety.

The FCAI represents ATV importer/distributors Honda, Kawasaki, Polaris, Suzuki and Yamaha.”

NZ quad bike fatality

On 26 November 2009, a contract worker on a New Zealand dairy farm was found seriously injured after his quad bike “flipped over on to him”. The details of the incident according to the New Zealand Police statement are included below.

A Department of Labour spokesperson said he was unable to provide any information about the incident other than that they are investigating.

Our sympathies go to Mr Wilson’s family and all those involved in the incident

“A dairy farm worker was been killed this morning in what appears to be a tragic quad bike accident.

Police were contacted around 7.35 this morning (Thursday, 26 November) when 40-year-old Rhys Mark Wilson, from Alton who is a sharemilker at a farm in Manutahi, near Hawera, was found in a gully on the farm by a co-worker. The worker had gone looking for Mr Wilson because the cows had not been brought in for milking.

CPR was administered and this continued when emergency services arrived on scene but they were unable to revive him.

OSH and police have carried out an investigation and it is believed that the accident happened around 5am when Mr Wilson was rounding up the cows for milking. He had gone down into a gully, probably to retrieve some stray cows and it appears that as he attempted to traverse a steep slope the quad bike he was riding flipped over on to him.

OSH has recovered the bike as part of its investigation and the Police are investigating on behalf of the Coroner.”

Truck safety talkback

On November 25 2009, NPR’s show Talk of the Nation conducted some discussions with truckers on their safety needs for the first part of the program. (Audio is available HERE)

The emphasis was on the conduct of drivers in vehicles and trucks but there is some discussion on the VORAD forward radar system applied to one of the tucks. It was refreshing to hear from a user of this technology which sounds almost like an advanced proximity system that has become common in aircraft.

There is considerable time spent with William Cassidy, the Managing Editor of Journal of Commerce. Cassidy discusses the pressures to speed and, thankfully, mentions some of the organisational pressures, such as paying by the mile.

One talkback caller says that fatigue from driving a car is different from driving a truck. Although a truck cabin may be full of more distractions than the cabin of a car, the caller says that the constant distraction equates to greater attentiveness.

Logic does not necessarily apply to driving but if we accept the caller’s position on truck driving being less fatiguing because of increased vigilance, would riding a motorcycle be even safer because of the need for the rider to constantly maintain balance?

Cassidy talks about the importance of perspective in considering these issues, the same reason for everyone’s common sense being slightly different.

He also discusses the “hours of service” rules, driving and rest limits that may be familiar to those of us outside the United States.

Dan Little, owner of the Little & Little Trucking Company, says that education at high school level would be the most successful measure for increasing safety for truck drivers. The US has a system of driver education in the school system that few other countries have so truck awareness in this context may be useful.

Placing the responsibility on an individual is a popular perspective and one that we can see reinforced on a daily basis but by focusing too much on this perspective reduces the need to innovative design of motor vehicles. It also necessary to consider any viable alternative freight transport options.

Many listeners will also be familiar with some of the discussion about the reliability of regulatory data collection. It is an argument that is echoed in many Western countries, particularly on the issue of uniformity of rules, consistency and harmonisation.

Little’s complaints about fatigue assessment by regulators is an argument that each country that is introducing fatigue regulations needs to consider. The comments also indicate the type of perspective that regulators will need to counter or integrate in their enforcement strategies.

Kevin Jones

Serious injuries can occur regardless of good OHS intentions

SafeWork South Australia has illustrated a situation that is common in Australian workplaces – no matter how hard one tries to ensure safety, things can still go wrong. In a court case on 20 November 2009, four farm operators were fined over a foreseeable incident that cost a 20-year-old the sight in one eye as well a fractured skull and paralysis, from falling three metres. According to a SafeWorkSA media release

“The incident occurred in May 2006 as the farmhand, aged in his early 20’s, was working on a large stock crate prior to mustering sheep for shearing. The crate had been borrowed from a neighbour. The farmhand had to stand on a small platform three metres off the ground and operate a manual winch to lower a ramp within the crate.

During this task, the winch handle forcefully struck the man in the face, after which he fell from the platform to the ground. This resulted in skull fractures and the loss of sight in his right eye, and spinal damage, which left him paralysed.”

The farmers had preventative management measures in place prior to the incident and have made considerable changes to the workplace to enable the worker to return to work.

The comments of Industrial Magistrate Stephen Lieschke in his judgement are worth noting

“While (they) believed they were being comprehensive in their safety improvements, they appear not to have given the same attention to the stock crate as to their own plant and equipment, probably because it was occasionally borrowed to them.”

The defendants were fined $A28,000, a hefty fine compared to some given out in the same jurisdiction. This figure was after a higher than usual 30% penalty reduction. Industrial Magistrate Lieschke applied the discount because of an “exceptionally high level of demonstrated contrition”. The magistrate puts it this way

“General deterrence does require a substantial penalty due to the prevalence of serious injury from the obvious danger of unprotected work at height, and due to the need for employers to take a structured risk assessment and control approach to all work processes and plant.

As first offenders the defendants are each exposed to a maximum fine of $100,000. In my opinion a notional total penalty based on a starting point of a fine of $40,000 is appropriate after taking account of all the above circumstances. After reduction by 30% this results in an aggregate penalty of $28,000. This in turn results in a fine of $7,000 for each defendant.

I also record a conviction against each defendant.”

SafeWorkSA advised SafetyAtWorkBlog that they did prosecute the owner of the stock crate but that, in February 2009 also heard by Industrial Magistrate Lieschke, the charges were dismissed.

Also, the injured worker, Kerrin Rowan, received a worker achievement award from WorkCover in 2008 and clearly the support from the local community is important.

Kevin Jones

Category: transport

Big fine for Queensland Rail – big risks in rail

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Quad Bikes – industry response

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Australian research figures into quad-bike deaths and injuries

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Further quad bike safety information

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NZ quad bike fatality

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Truck safety talkback

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Serious injuries can occur regardless of good OHS intentions

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