Safety messages

Background

With the development of new signalling technologies, railways across Australia are adopting advanced signalling systems such as ETCS (European Train Control System) and CBTC (Communication Based Train Control) onto existing lines. The rollout of these technologies may require an ‘interim interoperability solution’ to allow operations to continue through the transition and implementation period.

Effective safety critical communication is fundamental to any rail transport operator’s (RTO) safety management system. While there have been marked improvements in industry performance in this space, ONRSR’s data and infield insights tell us communication continues to be a factor in many reportable occurrences.

ONRSR’s latest digital incident recreation focuses on how rail transport operators and rail infrastructure managers can safeguard against the risks posed by large scale maintenance works in the vicinity of live railways.

In this second part of ONRSR’s focus on safety culture, we continue to look at practical steps rail transport operators can take to promote a positive safety culture, as required by the Rail Safety National Law. [Clause 3 of Schedule 1 of the Rail Safety National Law National Regulations]

Safety culture is the way safety is perceived, valued, and prioritised in an organisation. It is a result of individual and group values, attitudes, perceptions, competencies, and behaviour that determine the commitment to, and proficiency of, an organisation’s health and safety management.

ONRSR wants Rail Transport Operators to renew their focus on the quality assurance processes they have in place to ensure contracted maintenance work is carried out safely and effectively.

An Emergency Management Plan (EMP) is a written set of instructions outlining how a rail transport operator can manage emergencies including fires, collisions, derailments and evacuations.

During regulatory activities and interactions, ONRSR identifies both good and poor practice when operators undertake changes to their railways.

A current ONRSR investigation has highlighted a concerning issue where safety critical staff such as protection officers are not attending pre-possession planning meetings.

During regulatory activities and interactions, ONRSR identifies both good and poor practice regarding rail equipment type approval.

During regulatory activities and interactions, ONRSR identifies both good and poor practice from rail operators’ investigations reports.

ONRSR investigations and those conducted by other regulatory authorities have identified both good and poor practice when managing risks that arise when unexpected changes occur during railway operations.

In this safety message, ONRSR is highlighting some of the ways rail transport operators and rail infrastructure managers can apply a human factors lens to maintenance.

ONRSR is growing increasingly concerned about the prevalence of ageing infrastructure on Australian railway networks and is calling on operators to work closely with it to find appropriate solutions to address the issue.

ONRSR’s latest digital incident re-creation is based on a potentially disastrous incident that highlights the need for absolute vigilance in adhering to the fundamentals of a safety management system.

ONRSR is highlighting some of the key good practices and requirements for effective management of railway Signalling, Communications, Electrical and Control Systems (SCE&CS).

ONRSR is highlighting some of the key good practices and requirements for effective management of freight and passenger rolling stock.

ONRSR is highlighting good practices and requirements for effective management of railway track infrastructure

ONRSR is highlighting some of the key good practices and requirements for effective management of railway bridges.

ONRSR is highlighting the risk of lineside fires and detailing a range of effective controls.

ONRSR is highlighting the risk of rolling stock runaways in yards and sidings and detailing a range of effective controls.

In conducting ONRSR’s regulatory activities, ONRSR has found that some operators are undertaking a risk assessment as an administrative task or hurdle rather than as a process to support or guide their decision-making.

ONRSR is highlighting the dangers of straying from documented processes when designing and maintaining operations and infrastructure.

As the saying goes, what can go wrong will go wrong and it’s this reality ONRSR wants rail transport operators to more actively consider when assessing what have been generally low safety risks.

ONRSR conducts regulatory activities, including audits, inspections and site visits, across multiple operators and sectors. In conducting these activities, ONRSR often observes and identifies common safety themes and issues. In this series of safety messages, ONRSR highlights these issues, how they can potentially increase risks to rail safety and what better practice can look like to minimise the potential risks.

In this safety message - the first in a new series - ONRSR identifies a number of potential scenarios whereby informal or ad hoc processes and procedures can undermine a safety management system and create safety issues.

ONRSR’s first digital incident re-creation of 2022 details what can go wrong when safety culture is eroded and safety systems are not prepared, explained and executed correctly.

ONRSR is reminding rail transport operators about a range of risks, causes and controls associated with fires in underground tunnels and stations (FTUGs).

ONRSR is reminding rail transport operators (RTOs) about a range of risks, causes and controls associated with fires and explosions on passenger rolling stock.

ONRSR is reminding rail transport operators about a range of risks, causes and controls associated with sticking brakes on all types of rolling stock.

ONRSR is reminding rail transport operators about a range of risks, causes and controls associated with passenger falls between the platform and train.

ONRSR is asking those rail transport operators (RTOs) – with Network Control centres – to ensure network controllers are properly trained in the event of runaway incidents.

ONRSR is reminding rail transport operators about a range of risks, causes and controls associated road vehicles or vessels striking rail bridges.

ONRSR is reminding operators of the importance of managing the risks of SPADs and what the consequences of not doing so can potentially lead to.

ONRSR is reminding rail transport operators about a range of risks, causes and controls associated with short warning times at level crossings caused by train overspeed or procedural breaches.

ONRSR is reminding rail transport operators about a range of risks, causes and controls associated with short warning times at level crossings caused by wheel-rail interface issues.

Note: As a result of the National Rail Safety Data Strategy implementation, from 1 July 2022, A1 SPADs are Category A Proceed Authority Exceedances. Further information about reporting and occurrence data submission requirements can be found here

ONRSR is reminding rail transport operators about a range of risks, causes and controls associated with train to train collisions.

ONRSR’s first digital animation for 2021 focuses on a worksite protection occurrence and provides key learnings and advice for operators in relation to work on track.

An ONRSR investigation into a recent runaway incident revealed a feature of the Wabtec air brake system that is now highlighted to rail transport operators.

The systems, machinery, hardware and software used to run rail operations are often necessarily complex, but ONRSR is becoming increasingly aware that operators are not always fully aware of the detailed operational specifications of their many and varied pieces of kit.

ONRSR identified track worker safety as one of its inaugural national priorities in 2016, ensuring the issue was the subject of a sustained period of regulatory attention.

In this, ONRSR’s second digital re-creation, we look at the issue of uncontrolled movements and what happens when rail safety workers take shortcuts and ignore processes and protocols.

ONRSR is advising operators to assess competency of network controllers following an emerging trend.

Training for an emergency situation is important so that it becomes routine, as much as possible.

This digital recreation explores the issue of a communications breakdown that resulted in a near miss for a track worker

Regardless of the current circumstances, the principles of risk management, risk control, and active supervision continue to be a legal and critical requirement even if there is a need to perform work in different conditions.

ONRSR’s rail safety officers (RSOs) are our primary interface with accredited rail transport operators and they are based in each of our offices around the country

ONRSR recently worked with the Australian Society of Section Car Operators to address an outdated safety management system and safety culture. The experience serves as an important reminder to all rail transport operators to ensure safety is always the top priority

rail transport operators are reminded that wheel loads effect safe guidance of vehicles on track with excessive loads leading to damaged rolling stock components and track structures.

This document shares findings made from a runaway incident that occurred on 31 July 2019 in Whyalla, South Australia that should be used as an input to the risk review processes for operators managing a similar operating scenario.

ONRSR has developed new guidance for rail transport operators about the potential causes of incidents where people get stuck in rolling stock doors. It includes information regarding the existing controls available to eliminate or minimise the risk.

ONRSR is emphasising to all Rail Infrastructure Managers (RIMs) the increased risks posed by poorly maintained track following a series of recent derailments.

ONRSR is reminding all operators of the importance of careful planning when carrying out Track Occupancy Authority and Local Possession Authority activities.

This safety message is directed to coal loading operators and any other rolling stock operators responsible for loading coal into wagons.

Following recent incidents and observations the Office of the National Rail Safety Regulator (ONRSR) is reminding all operators of the importance of a system engineering approach.

Following recent incidents, and a review of the Office of the National Rail Safety Regulator’s own compliance and inspection activities, ONRSR is reminding all operators of the important role rolling stock maintenance plays in avoiding safety critical component failures.

Some rail transport operators (RTO) may choose to apply arrangements from enterprise bargaining agreements to their fatigue risk management program. In this instance there are strict obligations that an RTO’s safety management system must meet.

ONRSR reminds all rail transport operators to be aware of the inherent risks associated with undertaking emergency or unplanned maintenance.

ONRSR is reminding all rail transport operators to be aware of the inherent risks associated with undertaking emergency or unplanned maintenance.

An ATSB-identified limitation of use of the bio-mathematical model FAID has relevance to the rail industry.

Asbestos has recently been found in friction wear plates in the suspension systems of rail carriages.

A review of the metallurgical and associated factors covering eight wheel failure incidents, issued for the benefit of like-for-like railways.

Sets out ONRSR's road rail vehicle (RRV) human factors observations and analyses.

The ONRSR is concerned about the risk of permanently coupled pairs of freight wagons, which share a braking system, becoming uncoupled and resulting in a runaway. Rail operators are expected to reassess the risk/s associated with permanently coupled wagons and consider additional measures to mitigate these risks.

Australian rail operators may need to review and revise risk registers to manage the hazards associated with ‘shattered rim’ following two recent incidents, which may be indicators of a larger safety issue for the industry.

Investigation reports into rail accidents overseas can provide valuable lessons learned which, when applied, may reduce the risk of these incidents occurring in Australia.

The ONRSR has been working closely with the rail industry to assist in the identification and management of risks associated with the operation of Road/Rail Vehicles (RRVs).