Monday, April 22, 2024
Wallan - 20/02/2020 - A Case Study
At a Glance
WHAT HAPPENED?
On 20 February 2020, a passenger train travelling from Sydney to Melbourne derailed on entry to the crossing loop at Wallan, north of Melbourne. Two rail safety workers received fatal injuries and several passengers were transferred to hospital. At the time of the incident signalling in the area was not operational, with passage of trains being controlled through a system of manual train authority working.
WHY?
Pressure for faster train movements resulted in unauthorised and unapproved methods of working that created a single point of failure. Contributing factors included:
- Inadequate or lack of risk assessments
- Gaps in safety management systems
- Poor competency assessment and the use of inexperienced persons in safety critical roles
- Poor contractor management and a lack of supervision or audit processes
- Poor communication protocols and distribution of safety critical communication
- Circumvention of published rules and procedures
ONRSR DRIVEN SAFETY IMPROVEMENTS:
Communication of safety critical information
Management of unplanned operational changes
Risk management in accordance with SMS
Contractor Management
Competency and Training reviews/reforms
The Investigation
The post incident investigation by ONRSR identified the direct cause of the derailment was excessive speed while negotiating the turnout at Wallan, due to the driver being unaware of changes that had taken effect to an improvised safe working system.
This was the result of failures by NSW Trains and the Rail Infrastructure Manager, the Australian Rail Track Corporation (ARTC) to ensure the driver was fully aware of the improvised safe working system, and the changes imposed by subsequent train notices.
The incident had its origins in a sequence of events that degraded operational capability and led to a change of operating procedures by ARTC. These revised procedures were ultimately poorly, or simply not, communicated to impacted rail safety workers by NSW Trains and ARTC.
"The improvised safe-working system was a significant departure from ARTC’s published rules for degraded mode working….No formal structured risk assessment was conducted before this working was introduced.."
ONRSR Investigation Report
Sequence of events
The sequence began with a road vehicle (truck) striking an aerial cable at a level crossing on February 3rd, sparking a fire in an adjacent relay room which caused critical damage to signalling equipment. This resulted in signalling in the vicinity of Wallan defaulting to STOP (displaying red), a situation that required network controllers to verbally instruct train drivers on how to proceed at reduced speeds through the section of track.
The speed restrictions quickly led to congestion and saw time pressure build. In response, ARTC adopted a further revised safe working arrangement whereby it prescribed the use of an on-ground signaller, and an Accompanying Qualified Worker (AQW) to ride with the driver of the train to advise of the changed track conditions.
Meanwhile, in the days before the incident at Wallan, a train driver refused to proceed through a red signal in the area – apparently unsatisfied with only the verbal instructions of network control which he believed was a breach of procedure. This train waited stationary for more than two hours before the red signal was extinguished. This occurrence led to ARTC further revising its already degraded safe working arrangement by extinguishing all signals, removing the need for the driver to repeat back instructions from network control (as is standard practice) and placing responsibility for speed advice to drivers with the AQW.
Finally, in preparation for signal testing, ARTC decided to re-route trains off the Main Line and through the Wallan Loop to facilitate track maintenance – a decision made by a person without track engineering qualifications.
This decision resulted in a further revision of the safe working arrangements and while such updates, known as train notices, are published on the ARTC’s web-based portal, NSW Trains access to the portal had been discontinued and ARTC did not use alternative channels, such as email, to ensure the notices were sent and received.
"The second amendment...fundamentally changed the risk profile of train operations. Situational awareness for drivers was diminished by extinguishing signals. The AQW (for which there is no definition nor rules and procedures) had no authority or knowledge to advise drivers on speed management. "
ONRSR Investigation Report
Safety Improvement
ONRSR has worked extensively with both New South Wales Trains and ARTC in the aftermath of the fatal derailment at Wallan to ensure that safety improvements were made with a view to preventing incidents of this nature in the future.
The following incident specific activities were carried out in addition to broader work done via the ONRSR National Priorities programme that has included a focus on the following.
Communication of safety critical information (SCI)
Both ARTC and NSW Trains have made significant improvements to the way they manage and communicate safety critical information via the development of dedicated safe working improvement programs. ARTC has now established a standalone framework for managing, updating, disseminating and confirming acceptance of safety critical information complemented by the use of network information books and the development of an Online Safe Working Portal.
NSW Trains has also taken significant steps toward improving its practices via a comprehensive review and updating of its suite of SCI documentation. This included the development and introduction of a four-phase Communication of Safety Critical RIM Information Procedure covering the receipt, administration, distribution and control assurance of SCI. Development of a Safety Assurance Statement for its SCI process and the establishment of a SCI Working Group were also important safety improvements. The group is accountable for ensuring that NSW Trains delivers an effective SCI distribution process and moves to a future solution that identifies and distributes relevant safety critical and operational information and notifies crew in near real time. ONRSR has, and will continue to, conduct meetings, site visits and cab rides to verify that NSW Trains drivers are receiving SCI in a timely manner.
In December 2021, NSW Trains commenced a Digital Safety Critical Information (DSCI) project for designing, developing, and implementing a DSCI portal that will ensure time critical and relevant safety critical information is delivered to frontline employees ready for the start of their trip. The aim is to have safety critical information automatically collected from Rail Infrastructure Managers and then registered, assessed, and validated via an online portal which will then produce hard copies. The DSCI back-end portal was completed in January 2024, at which point the project progressed to testing with an expected "go live" date by end of May 2024.
Management of unplanned operational changes
ONRSR obtained a commitment from ARTC that for the introduction of safe working arrangements that are inconsistent with established rules, an Operational Review and Risk Assessment will be completed, endorsed, and approved by the ARTC Executive before being introduced (i.e. such arrangements cannot be made in immediate response to an operational issue).
Risk management in accordance with SMS
ONRSR identified areas within ARTC where safety assurance processes are in place to manage key safety risks and has been working to ensure that ARTC’s senior management are fully aware of and actively monitoring the effectiveness of these arrangements in managing key risks. This has included oversight of how ARTC is managing risk in accordance with their SMS and that nominated controls related to the risk management system are being applied at all times.
Contractor Management
ONRSR thoroughly examined ARTC’s processes and procedures for the management of contractors engaged to undertake rail safety work for ARTC’s railway operations. The effective application of this documentation within ARTC’s operations is the subject of ongoing regulatory activities.
Competency and Training reviews/reforms
Since the Wallan incident ONRSR has reviewed the development and implementation of the following ARTC safety improvement activities:
- An ARTC competency for the domain knowledge and soft skills required for working on ARTC networks by implementing a non-technical training competency to enhance behavioural skills and improve safe working processes. These include:
- Communication
- Trust
- Making high quality decisions
- Leading by example,
- Increasing confidence
- Feedback and listening
- Updated core technical knowledge requirements for Protection officers.
- Defined a new ARTC Hierarchy of Protection for application to all ARTC Networks.
- A program to address Network Control Officer competency related to emergency communications.
Rail Transport Operators and Rail Infrastructure Managers around Australia are encouraged to reflect on the circumstances of the tragedy at Wallan and to ensure that the lessons of this occurrence are learned and applied to their own operational models. For further information on the Wallan incident and the work ONRSR has done to drive safety improvements, please contact your local ONRSR office.