gemma read - university of the sunshine coast

RISSBRailSafetyConference2017

DrGemmaRead,CentreforHumanFactors&SociotechnicalSystems,UniversityoftheSunshineCoastAssociateProfessorAnjumNaweed,AppletonInstituteforBehaviouralScience,CentralQueenslandUniversityProfessorPaulSalmon,CentreforHumanFactors&SociotechnicalSystems,UniversityoftheSunshineCoast

Controlfailuresintrackworker collisions:Whatcanwelearnfromrecentincidentinvestigations?

Trackworkersafety

• Over400occurrencesrelatingtotrackworksafeworkingbreaches(ONRSR,2014–2015)

• Trackworkersafetyacurrentregulatorypriority(ONRSRCorporatePlan2016-19)

Asystemsperspective

• Worksystemscompriseindividuals&organisationsatdifferentlevels• Shareresponsibilityforsafety

• Controlsareimposedtop-down• Ensurethecontrolofhazards

• Feedbackisprovidedbottom-up• Determineifthecontrolsareeffectiveinmanagingrisk

STAMP• Systems-basedmethodforunderstandingsafety&riskmanagement• DevelopedbyProfessorNancyLeveson,MassachusettsInstituteofTechnology• Initiallydevelopedforhazardanalysis&systemdesigninaerospace

• Viewsaccidentsnotintermsofcomponentfailures• E.g.technicalfailure,humanerror

• Arguesaccidentsoccurwhenthereisfailureofanadaptivefeedbackfunctiontomaintainsafetyovertime• Howcontrolandfeedbackmechanismsfail

ASTAMPmodelforrail

AutomatedcontrollersVehicles&Vehicle

systems

ControlledProcessTransport

HumancontrollersDriver

Actuators Sensors

Level4:Localmanagementandsupervision

Worksitesupervisors

Operatingprocess(Traindriving)

Level3:Operationaldelivery&management

Level2:Governmentagencies,industryassociations,usergroups,insurancecompanies,courts,universities

Stategovernmenttransportauthorities

Userassociations&industrylobbygroups(e.g.ARA)

Courts

Universities/researchinstitutions

Advocacygroups(e.g.Tracksafe)

Insurancecompanies

Level1:Parliament&legislatures

DepartmentofInfrastructure&

RegionalDevelopment

NationalTransportCommission

Drivertrainers

Registeredtrainingorganisations

Governmentresearch

fundingbodies

Coroner

StandardsAustralia

Unions(e.g.RTBU)

Traincontrollers

Policeagencies

Railoperators

Consultants&researchgroups

Generalmedia&industrymedia

AustralianLocalGovtAssociation

Internalauditors

Hospitals(injurydatacollections)

TheConstitutionofAustralia

Policeofficers

Strategy,policy&actionplansLaws,rules&regulationsFunding/resourceallocationCoordination&agreements

IncidentreportsMaintenancereportsInfringementhistory

ObservablebehavioursDrivingperformancedataTrafficflowdataComplaints

Targets&performancemeasures

Education

Supervision

Enforcement&otherpenaltiesInstruction


Strategicresearchpriorities

AdvocacyPlanning&policydevelopmentFunding/resourceallocationRecommendations(e.g.Coroner)Audits&inspections

Contractualagreements

Standards&codesofpracticeStrategy,policy,procedures&actionplans

Legalpenalties(fines,etc)


Caselaw

Researchfundingallocation

Funding/resourceallocationStandards&codesofpracticeInitiativesRegistrationInsurancepolicies

Enforcementplanning&strategies

Researchrecommendations

InfrastructuremanagementplanningPolicies,procedures,workinstructions(incl.JSAs)

Training&competencymanagementTargets&performancemeasuresAccreditation/licensingAudit&inspection

Infringementdata&statisticsIncidentdata&statisticsDelays/servicedeliverydata

ComplaintsTripdata

MaintenancereportsFailuresintesting&inspection

Safety&riskdata&statistics

TrafficflowdataTripdata

Researchfindings

Researchproposals

Performancereporting(e.g.punctuality&reliabilitydata)

Financialreporting

Insurancedata

Advocacy

GovernmentreportsFinancialreportingAdvocacy&lobbyingResearchproposals,reports&findings

Draftlegislation

IncidentdataMaintenancereports

Complaints

Investigationfindings

Publicopinion

Controls Displays/interfaces

Railwayinfrastructure

Observablebehaviours

Weather-relatedfactors Signals&signs

Approvals

Ambientlighting(day/

night)

Surroundingnatural

environment

RailIndustrySafety&

StandardsBoard

FederalParliament

StateParliaments

LocalCouncils

Guidelines

Memorandumsofunderstanding

Railinfrastructuremanagers

Publicopinion

Advocacy

Emergencyserviceagencies

Politicalparties

Politicalobjectives

Auditors-General(QLD&federal)

Incident&injurydata&statistics

Ombudsman

Emergencyresponders

StatePremiers&Cabinet

PrimeMinister&Cabinet

Auditresults/evaluationfindings

Standardoperatingprocedures

Safetycampaigns/education


Transport&Infrastructure

Council

StateParliamentaryCommittees

COAG

Evaluation

Collectiveagreements

OfficeoftheNationalRail

SafetyRegulator

WorkplaceHealth&Safety

regulatorsLegalpenalties

Legalpenalties

Dynamictrafficmanagement(e.g.controlofsignals)

DepartmentofPremier&Cabinet

DepartmentofPrimeMinister&

Cabinet

PublicopinionAdvocacy

Policydevelopment

Audit

Externalauditors(e.g.RSOs)

VehiclepositiondataDriverbehaviour&vehicle

performancedata

Key:

Controlmechanism

Feedbackmechanism

....

....

Actorwithformaldecisionmakingauthority

Actorwithoutformaldecisionmakingauthority

Level5:Operatingprocess&environment

Rollingstock&infrastructureinspectors

StateLocalGovt

Associations

FederalParliamentaryCommittees

Researchpriorities Researchfindings

Operatingenvironment

Complaints

Coordinationgroups(e.g.VRCSSC)

AustralianTransport

SafetyBureau

State-basedtransport

investigationbodies

State-basedrailsafety

regulators

InvestigatorsStationmasters

Contractors/labourhireagencies

Railoperationscontrolstructure

Complaints

Registration/accreditation

Safeworkingrules

Safeworkingrules

AutomatedcontrollersSignallingcontrolsystem

ControlledProcessSeparation

HumancontrollersSignaller/area

controller

Actuators Sensors

Operatingprocess(Signalling)


Trackworkers


HumancontrollersProtectionOfficer/

Lookout

Actuators Sensors

Operatingprocess(Trackworkerprotection)

Emergencycommunications


Trackaccessunits

Passengers/membersof

public

Pre-starthazardassessment/checklistPre-startbriefings

Equipmenteventrecordingdata(e.g.blackbox)

Approvaltoaccesstrack

Approv

altopro

ceed

Observ

ablebeh

aviours

AustralianSkillsQualityAuthority

Requirementsforquals,unitsofcompetency

Useofh

ornto

warn

Roles&responsibilities

Approvaltoaccess

track

Confirmation

Fitnessfordutymanagement

Memoranda,orders,circulars,bulletins

Organisational&industryculture

Emergencycommunication

Correctiveactionstaken

Health/medical

professionals

Healthrecords

Confirmation

Stationstaff

InstructionsTra

incons

picuity

Location

Location

Driver&train

Signaller&

signallingsystem

Trackworkers Railenviron-

ment

Traincontrollers,Supervisors,Auditors,Investigators

Railinfrastructuremanagers,Railoperators,Contractors

Govt departments,Regulators,Courts,Industrybodies

Federal&StateParliament,MinistersCulture

Legislation

Accreditation

SMS

Supervision Incidentreports

Incidentdata

Incidentstatistics

Advocacy/lobbying

ApplyingSTAMPtotrackworker incidents/accidents• 7publiclyavailablereports(2010-2016)• Australia-wide• Involvingworkersontrack• Significantoutcomesorpotential– fatalities,injuries,nearmisses• Reviewedtoidentify:• Controlfailures• Feedbackfailures


systems



Actuators Sensors


Worksitesupervisors






Courts



Insurancecompanies



RegionalDevelopment


Drivertrainers


Governmentresearch

fundingbodies

Coroner

StandardsAustralia

Unions(e.g.RTBU)

Traincontrollers

Policeagencies

Railoperators




Internalauditors



Policeofficers





Education

Supervision









Caselaw





InfrastructuremanagementplanningPolicies,procedures,workinstructions(incl.JSAs)



ComplaintsTripdata




Researchfindings

Researchproposals


Financialreporting

Insurancedata

Advocacy


Draftlegislation


Complaints


Publicopinion





Approvals


night)

Surroundingnatural

environment

RailIndustrySafety&

StandardsBoard

FederalParliament

StateParliaments

LocalCouncils

Guidelines



Publicopinion

Advocacy


Politicalparties

Politicalobjectives



Ombudsman

Emergencyresponders








Council


COAG

Evaluation



SafetyRegulator



Legalpenalties




Cabinet


Policydevelopment

Audit



performancedata

Key:

Controlmechanism

Feedbackmechanism

....

....





StateLocalGovt

Associations




Complaints


AustralianTransport

SafetyBureau


investigationbodies


regulators




Complaints


Safeworkingrules

Safeworkingrules




controller

Actuators Sensors



Trackworkers



Lookout

Actuators Sensors




Trackaccessunits


public




Approv

altopro

ceed

Observ

ablebeh

aviours



Useofh

ornto

warn

Roles&responsibilities

Approvaltoaccess

track

Confirmation

Fitnessfordutymanagement

Memoranda,orders,circulars,bulletins

Organisational&industryculture

Emergencycommunication

Correctiveactionstaken

Health/medical

professionals

Healthrecords

Confirmation

Stationstaff

InstructionsTra

incons

picuity

Location

Location

Strathfield,NSW

• 1April2010,5:00am• Nearmisswithfourtrackworkers• Events:

SignalmaintenanceteamontrackatStrathfieldduetopointsfailure,using

‘noauthorityrequired’worksiteprotectionmethod

Lookoutsawwarninglightextinguishandinformedcrew

Memberofteaminstructedlookouttokeeplookingoutforthetrain– continuedwork

Driversawcrew,soundedhorn,appliedemergency

brake

Workersmovedofftrack,driverreportedtrainstoppedatthe

points

NearLaverton,Vic

• 2October2015(publicholiday),9:16am• Infrastructuresupervisorstruckbytrain,sufferedseriousinjuries• Events:

Trackworkersassembled,plannedtoundertakedogspikeremovalsatLaverton

Workssupervisorarrives,beginmarking

sleepers

TFPCarrangeslookoutprotectionforsupervisor

TraindepartsLavertonstation,driversounds

horn

Lookoutwarnssupervisoroftrain,believessupervisormovingaway,gives‘All-Right’handsignal

Traindriversoundshorn,emergencybrake

application,trainstrikessupervisor

SummitTanktoDombarton Section,NSW

• 17July2012,2:48pm• Nearmisswiththreeworkersinspectingaviaduct• Events:

StructuresManager(PO)supervising

contractorsduringsiteinspectionofviaduct

Contractorsindicateneedtoinspect

damagefromtracklevel

POandcontractorsmoveontoviaductandalongwalkwayby

10m

Trainapproachesviaduct,driverseesworkersahead,applieshorn

andemergencybrakes

Workersnoticetrain,movetowardtraintoendofthe

viaduct

Workersclearendofviaductwithtrainapprox.5maway

Guildford,WA

• 10February2015,10:35am• Protectionofficerstruckandkilledbytrainwhileassessingoperationofpedestrianlevelcrossinggates• Events:

POonsitewithtwocontractorsfor

routinesignalmaintenance

Downsuburbanpassengertrain

approachescrossing

MaintainersnoteissuewithNWpedestriangate,POandmaintainerdecidetocomparewithSWgate

Crosstracksafterdowntrain,levelcrossingwarningsremainactive

MaintainermentionstoPOthatanothertrain

approaching

Drivermakesemergencybrakeapplication,train

strikesPO

POexaminesgatecontrolarmfrom

trackside,turnsandmovestowardstrack

Driversoundshorn,maintainercallsoutto

warn

Kogarah,NSW

• 13April2010,1:08am• Trackworkerfatality,cleaningcontractor• Events:

POsupervisingcleaningcrewatvariouslocations

CSBimplementedforplatform3

Workcompleted,POcallsareacontrollertofulfilforplatform3,requestsCSBfor

platform1

Areacontrollerstates‘blocksareon’,norepeatbackorconfirmationno

trainsinsection

Workcommencesatplatform1,POkeepswatchonadjacent

track

Areacontrollerrealisestraininsection,callscustomerservicetomakeannouncement

Confusionaroundmeaning

ofannouncement

Driversoundshorn,workers

attempttoclimbplatform

3workersmoveontolivetrack,1struckbytrain

Bankstown,NSW

• 29October2010,12:53am• Nearmisswithfourcleaningcontractors,trainstopped60mfromcontractors• Events:

POsupervisingworkcrewperformingcleaningatvarious

locations

Controlledsignalblockidentifiedasmethodofworksite

protection

WorkersfinishedonDowntrack,POphotographingconditionaftercleaning

WorkerswaitfortraintodepartatUptrack,then

moveontotrackandbeginwork

POwalksaheadattemptingtocallareacontrollerand

photographingtrackpriortocleaning

POturnstowarnworkersastheyaremovingtosafe

place

Traindriverseesworkers,useshorn,appliesemergency

brakes

BetweenSeymour&Avenel,VIC

• 25July2011,1:51pm• Nearmisswithtrackmaintenancecrew,trainstopped26mfromworksite• Events:

TrackworkersperformingweldingonWestlineunderTrackWarrant–NChasblockonsignalSEY132toprotect

Trackmaintenanceinspectorrequests

permissionforpatrolinsamearea

NCauthorisesinspectionandadvisesofwelding

crew

Trackinspector

advisesclearofline

NCinadvertentlyremovesblockforTrackWarrant

Trainapproachesworksite,driverapplies

emergencybrakes

NCinadvertentlysetsroutefortraintodepartSeymour

&enterWestline

Analysis


systems



Actuators Sensors


Worksitesupervisors






Courts



Insurancecompanies



RegionalDevelopment


Drivertrainers


Governmentresearch

fundingbodies

Coroner

StandardsAustralia

Unions(e.g.RTBU)

Traincontrollers

Policeagencies

Railoperators




Internalauditors



Policeofficers





Education

Supervision









Caselaw





InfrastructuremanagementplanningSafeworkingprocedures/workinstructions(incl.JSAs)



ComplaintsTripdata




Researchfindings

Researchproposals


Financialreporting

Insurancedata

Advocacy


Draftlegislation


Complaints


Publicopinion





Approvals


night)

Surroundingnatural

environment

RailIndustrySafety&

StandardsBoard

FederalParliament

StateParliaments

LocalCouncils

Guidelines



Publicopinion

Advocacy


Politicalparties

Politicalobjectives



Ombudsman

Emergencyresponders





Safeworkingrules




Council


COAG

Evaluation



SafetyRegulator



Legalpenalties




Cabinet


Policydevelopment

Audit



performancedata

Key:

Controlmechanism

Feedbackmechanism

....

....





StateLocalGovt

Associations




Complaints


AustralianTransport

SafetyBureau


investigationbodies


regulators




Complaints


Safeworkingrules




controller

Actuators Sensors



Trackworkers



Lookout

Actuators Sensors




Trackaccessunits


public




*Laverton

**

Approv

alto

procee

d*

Observ

ablebeh

aviours



*

*

*

Useofh

ornto

warn

Roles&responsibilities*

*SummitTank

**

*

*

** *

*

Approvaltoaccess

track

Confirmation

*Kogarah*

*

*Fitnessfordutymanagement*

* *

Memoranda,orders,circulars,bulletins *

*

*

*

*

*

Organisational&industryculture *

Emergencycommunication*

*Correctiveactionstaken

Health/medical

professionals

Healthrecords*

*Guildford*

**

*

*

*

Confirmation

Stationstaff

Instructions

*Bankstown

*

*

*

*

*

*

*

*

*Seymour&Avenel

*

*

**

*

*

Trainc

onspicu

ity

*Strathfield

*

*

*

** *

*

Location

Location

*

Driver&train

Signaller&

signallingsystem

Trackworkers

Railenviron-ment

Traincontrollers,Supervisors,Auditors,Investigators

Railinfrastructuremanagers,Railoperators,Contractors

Govt departments,Regulators,Courts,Industrybodies

Federal&StateParliament,Ministers

Failedcontrols

ControlsnotimplementedControl No. Reports Example- Approvaltoaccesstrack

3 On arrivalattheworksite,thesupervisorwentontothetrackwithoutfirstconfirmingwiththeTFPCthatsafeaccesshadbeenarranged

- Pre-start hazardassessment/checklist

3 The siteteam…hadnotcompletedthepre-startchecklist

- Pre-startbriefing 2 …thesupervisor andthelookoutdidnotreceivethebenefitofasafetybriefingthatwouldhaveinformedthemoftheoutcomesoftheworksitehazardassessment,trainrunning,andthedesignatedpositionofsafety.

- Audit(process) 2 [thecontractor]hadnotyetcommencedmonitoringorauditingdocumentationcompletedbytheirPOsunderthiscontract

Control No. Reports Example- Pre-starthazardassessment/checklist

4 Thepreparationofworksiteprotectionplans…usingformspartlycopiedfromearlierjobsandfinalisedonthewaytoworksite…

- Pre-startbriefing

4 Thepre-workbriefdidnotmentiontheintendeduseoftemporarytrackbondinginordertomaintaintrackcircuitintegritytoavoidcontinuouslevelcrossingoperation

- Safeworkingrules

4 NARhasbeenthesubjectofscrutinyoveranumberofyearsbutnearstrikescontinuetooccurwithinworksitesusingitasthemethodofprotection

- Training&competencymanagement

3 …inductionandworksiteprotectiontraining…insufficientcoverageoftheemergencysafetyprecautionstobetakenbyworkersiftheyarecaughtonthetrackwithatrainapproachingandnosafeplacereadilyaccessible

Controlsinadequate

FeedbackmechanismnotimplementedFeedback mechanism No. Reports ExampleConfirmation 2 The trackworkersproceededontothetrackwithout

firstcheckingwhetherprotectionhadbeenestablished

Displays/interfaces 2 Lack ofintegrationbetweentraincontrolsystemsandpaper-basedsystemsusedtoissueandreturntrackwarrants

FeedbackmechanisminadequateFeedback mechanism No. Reports ExampleDisplays/interfaces 2 Thesignallingtechnologydisplayedovermultiple

screens…didnotprovideinformationregardingkilometrages.Further,itsdropdowncommandmenuboxesoftenobscureditemsinthedisplay

Summary • Somekeycontrolsareimplicatedacrossmultipleevents:

• Pre-starthazardassessment/checklists• Pre-startbriefings• Audit• Safeworking rules/procedures/workinstructions• Communication/confirmationattheoperationallevel

• Littleconsiderationofcontrols/feedbackabovethecompanylevel• Veryfewmissingorinadequatefeedbackmechanismsidentified• Fewexplicitreferencestoculture,althoughitisculturethatdrivesimplementationoftheSMS• Mayreflectinvestigationsfocusorconstraints

The Protection Officer explained that, on other similar occasions when he had had

cause to question the implementation of the CSB rule, methods of protection or

operational matters with the signallers, some had hung up on him, effectively preventing

him from doing the work

Questions• Dothefailuresidentifiedsuggestthelackofadaptivefeedbackfunctionstocontrolthesafetyoftrackworkers?• Howwellunderstoodistheimplementationofcontrolsontheground?Howdomandatedcontrolsfitwiththewaythatworkneedstobedone?• Howwelldoesinformationfeedbackupthesystemtoinformthecontinuousimprovementofcontrols?

Task

Task

Task

Workasimagined Workasdone

Needtoclosethegap

Futuredirections

• EnhanceourSTAMPmodel• Improverepresentationofculturalaspects/mechanisms• Considerationofrecommendationsfromreports– dotheseidentifyfeedbackmechanisms?

• Understandinginvestigationsaspartoftheadaptivefeedbackfunction

• Toolstosupportinvestigations• Tools/methodstoidentifyandclosegapsbetween‘workasimagined’and‘workasdone’intherailindustry

Thank-you

[email protected]&SociotechnicalSystemshttps://hf-sts.com/

@HFandSTS

@humanfactors2016

gemma read - university of the sunshine coast

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