SCENARIO 2 CASE STUDY: Australian Transport Safety Bureau Report – Safe Working Irregularity following Rail Track Maintenance
ATSB Report: What went right in this safe working irregularity?
On 30 October 2015, the Australian Rail Track Corporation (ARTC) scheduled track maintenance work (placement of ballast) to occur between Braxton and Farley on the Up main north line, Hunter Valley in NSW. During this planned track maintenance work, a safe working irregularity occurred on the rail corridor. To facilitate the work, the network controller at the ARTC network control centre north (NCCN) situated at Broadmeadow issued the protection officer a work on track authority. The authority excluded rail traffic from the defined track section between Allandale and Farley, permitting safe access for the work to proceed. The track maintenance work took place without incident. At about 0856, the track work was completed and the protection officer contacted the network controller to fulfil the work on track authority and return the track for rail traffic. While travelling on an access road within the rail corridor during its exit, a road vehicle involved in the maintenance work became bogged in a drain. The vehicle was situated approximately five metres from the nearest rail of the Up Relief line. The vehicle was located outside the danger zone, and therefore there was no requirement to employ a work on track method to retrieve the vehicle. Nevertheless, the protection officer in charge of the worksite made a safety assessment to exclude rail traffic from the portion of track to ensure the presence of workers in the rail corridor did not alarm a driver of an approaching train. The protection officer contacted the network controller and requested controlled signal blocking. The network controller authorised the work to commence, but only outside of the danger zone. After initial attempts to recover the vehicle failed, they decided that a front-end loader was required to free the vehicle. During this conversation and a subsequent conversation, the parties did not confirm their common understanding about the location of the worksite. Consequently, when controlled signal blocking was put into effect, a train had already passed the signal and was travelling toward the worksite. Workers on the site assumed the track was protected and were preparing to remove the vehicle when they noticed an approaching train. There were no injuries to people or damage to property. The Australian Transport Safety Bureau (ATSB) found that communication between the protection officer and network controller resulted in the misunderstanding of information that contributed to a safe working irregularity where controlled signal blocking was issued with a train (HV130) located between the protecting signal and the worksite. The rule and procedure associated with the issuing of controlled signal blocking did not manage the sequential communication of sufficient information to identify the worksite location before controlled signal blocking was acted upon. There is also no requirement in the rule or procedure applicable to controlled signal blocking to keep a permanent record detailing the specific information relating to its implementation, therefore increasing the likelihood of error during the read-back process. The ATSB Investigation Report is almost exclusively focused on what went wrong even though no harm came to workers. Let's look at what went right and whether no harm would occur if the circumstances were different.
Source: Case study extracted from ATSB Transport Safety Report, Rail Occurrence Investigation RO-2015-021, Safe Working irregularity involving Controlled Signal Blocking between Allandale and Farley, Hunter Valley, NSW , Final Report, 4 May 201
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