Waterfall Special Commission of Inquiry - Final Report: Government Response - February 2005

1. Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary.

Supported and being implemented.

2. A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency.

Supported in principle and being implemented through other means.

The RMC has touch screen dial up capability to Police, Fire Brigade and Ambulance. In addition, a dedicated phone line is available for Emergency Services incoming calls.

3. A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response.

Supported and being implemented.

4. The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network.

Supported in principle.

The RMC is equipped with a network mimic panel that currently gives train visibility on approximately 65% of the RailCorp network. Visibility of approximately 90% is targeted for 2008.

RailCorp will conduct a study of other options available, including GPS technology to provide a more precise location at any time of all operators' trains on the RailCorp network.

5. All train guards should be trained by RailCorp in the use, of the Metronet radio and instructed to use it in any emergency.

The training of guards in the use of Metronet radio is supported and being implemented.

The use of Metronet radio by guards in emergencies is supported in principle and RailCorp will review the operational and technical issues the recommendation raises.

6. Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail injury or harm.

Supported and being implemented.

7. Satellite telephones should be provided by RailCorp to all rail commanders at any emergency.

Supported and being implemented.

8. All signal telephones must be maintained by RailCorp in proper working order.

Supported and being implemented.

9. All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility.

Supported in principle subject to discussion between RailCorp and emergency services regarding operational and security issues.

10. A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network.

Supported in principle and being implemented through other means.

The State Emergency Management Committee advises a specific sub plan for rail would not provide additional response capability and it would not be consistent with the all Hazards approach. Instead the Commissioner's recommendations below about a specific Railway Disaster Plan will be incorporated in the overall State Disaster Plan (Displan) and RailCorp's Incident Management Framework

This Framework addresses all level of rail incidents including 'emergencies' and will be implemented early 2005.

11. The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment of a staging area remote from the accident site, in a unified command structure with the site controller co-ordinating the various emergency services through representatives of each service.

Supported and being implemented through the RailCorp Incident Management Framework.

12. The rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response.

Supported and being implemented through the RailCorp Incident Management Framework.

13. The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed.

Supported and being implemented through the RailCorp Incident Management Framework.

The RailCorp Incident Management Framework aligns with the State Displan, which requires the site controller to have control of the incident site.

14. The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident.

Supported and being implemented through the RailCorp Incident Management Framework.

15. The location of the command post for site control at the scene of any rail accident should be identified by NSW Police by a distinctive flashing light.

Supported and being implemented.

16. The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed.

Supported and being implemented through the RailCorp Incident Management Framework.

17. The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed.

Supported and being implemented through the Incident Management Framework.

18. RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents.

Supported and being implemented through the RailCorp Incident Management Framework.

The RailCorp Incident Management Framework was developed in consultation with emergency service agencies and it aligns with the State Disaster Plan (Displan). This framework addresses all level of rail incidents including 'emergencies'. See R10.

19. The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency.

Supported and being implemented through the Incident Management Framework.

20. All operational rail staff should be trained by RailCorp in the action check list relevant to each.

Supported.

21. The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency.

Supported in principle and being implemented through other means.

The RailCorp Incident Management Framework will be given to all emergency response agencies. In addition, RailCorp has provided access to emergency services to railway equipment for training purposes.

RailCorp has also produced a DVD covering rail specific emergency response matters for use by the emergency services for training their staff. 500 DVDs have been given to each of Fire Services, Ambulance and Police.

Emergency services personnel will be trained in rail hazard awareness using material provided by RailCorp. The very large number of emergency response personnel (including volunteer services) that may respond to a rail incident, means training of all personnel in the RailCorp Framework is unlikely to be achievable. Emergency Services will investigate with RailCorp extension of the DVD into a multimedia resource to improve the ability to educate wider numbers of emergency service workers.

22. The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and thereafter implement such improvements.

Supported and being implemented.

23. All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander.

Supported in principle and being implemented through other means. See R 21.

24. Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved.

Supported and being implemented.

25. Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel.

Supported and being implemented.

26. All rail employees should be trained by their employer to commence any emergency communication with the words "Emergency, emergency, emergency", thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred.

Supported and being implemented.

27. A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a "tie line" or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services.

Supported in principle and being implemented through other means.

See also R 2.

The RMC has touch screen dial up capability to Police, Fire Brigade and Ambulance. In addition, a dedicated phone line is available for Emergency Services incoming calls.

28. A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock.

Supported and being implemented.

An emergency services training facility is in place at Redfern with a platform, double decker carriage and black-out facilities.

29. All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications.

Supported and being implemented.

30. The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose.

Supported in principle and being implemented through other means.

ITSRR will introduce regulations including for rolling stock that set out the expectations (or performance outcomes) required of industry.

The regulations will be developed on a national basis, through the National Transport Commission process, to ensure consistent application across the Australian rail industry.

Notwithstanding the expectation that industry will develop and maintain appropriate safety standards, ITSRR will retain the power to mandate such standards if the industry clearly fails to deliver satisfactory safety outcomes.

31. All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation.

Supported in principle for further review.

ITSRR supports this for driver-only operations and will review its application on an industry-wide basis. It has been implemented on all RailCorp passenger trains.

Driver safety systems and train protection systems are interrelated but may also be implemented independently. Recommendations 31-33 need to be reviewed in light of this relationship.

All RailCorp passenger rollingstock have a minimum of two engineering defences (deadman, vigilance, trainstops) except 600 class (those operating in the Hunter Valley) which will be replaced from the end of 2005 with rollingstock that complies with this requirement. In the meantime on 600 class, the train guard travels with the driver as added protection for driver incapacitation.

32. RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 7 of this report.

Requires further detailed review.

The Government supports the implementation of additional train protection systems.

Implementation of level 2 ATP as detailed in the recommendation would involve the replacement of all line-side signalling on the RailCorp network with on-train control systems. In addition every intra and inter-state train accessing the network would also need to be equipped with level 2 ATP technology.

RailCorp has already retained consultants to undertake evaluation and risk assessment regarding implementation of additional automatic train protection systems on the RailCorp network.

RailCorp will work with the Australian Rail Track Corporation (which operates the interstate network) to develop, in conjunction with ITSRR and interstate rail regulators, a national standard for an automatic train protection system.

RailCorp will also undertake a comprehensive review which will include a risk assessment, technical feasiblity and cost benefit analysis of introducing level 1 ATP as well as level 2 ATP, as recommended by the Commission. Consistent with recommendation 34 any future options will need to be assessed by independent verification of acceptable risk.

33. All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report.

Requires further detailed review. See R 32.

34. RailCorp should undertake risk assessments of each of its activities as follows:

Supported and being implemented.

RailCorp has undertaken the development of a Risk Management Framework, with the assistance of external safety experts. The draft Risk Management Framework will be assessed against Recommendations 34 (a) to (h) to ensure the Framework addresses them.

(a) identify the features of the system, subsystem or activities that are to be risk assessed and managed, to determine what makes the system work in terms of equipment, infrastructure and human factors;

Supported and being implemented.

(b) identify all hazards that may exist within the particular system, subsystem or activity, whether it is a driver safety system, passenger safety system, engineering design system,, train maintenance system or involves human factors or performance;

Supported and being implemented.

(c) identify what controls are in place to eliminate or minimise the risks associated with any identified hazard;

Supported and being implemented.

(d) test the validity of the controls to ensure that the risk is eliminated or reduced to an acceptable level and, if not, institute additional or further control measures;

Supported and being implemented.

(e) specify, in safety documentation, the level of any residual risk;

Supported and being implemented.

(f) in the case of low probability, high consequence risks retain the services of an independent verifier of the risk assessments and controls to certify that all risks of such potentially catastrophic accidents have either been eliminated, or controlled to the extent identified by the independent expert;

Supported in principle for further review.

RailCorp will investigate the availability of independent experts willing to undertake this certification role.

(g) the Board of RailCorp certify that it regards any residual risk of a high consequence, low probability accident as acceptable, notwithstanding the severity of the consequences, by reason of the cost of further measures to control the risk; and

Supported in principle and being implemented through other means

The RailCorp Board is prepared to certify that the risk management processes designed to achieve this are in place.

(h) provide to ITSRR records of the processes of hazard identification, risk assessment, risk control, independent verification and certification, and any Board certification relating to any high consequence, low probability accident.

Supported.

35. The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable.

Not supported.

ITSRR is working with industry at the national level to identify appropriate risk assessment methods and consistent standards for regulators to accept risk assessments. This will provide rail operators with guidance on the level and depth of risk assessment required by them as part of Accreditation. ITSRR has undertaken a Risk Vulnerability Study to identify the significant risks faced by Rail Operators and the corresponding risk control measures. The National Transport Commission is also developing a Risk Acceptance Criteria Project to provide further guidance to the rail industry on acceptable levels of risk.

ITSRR's role in relation to operator risk assessment is to ensure that they have the competence and capacity to identify and control risks.

36. The ITSRR should impose a standard in relation to the collection and use of data from data loggers.

Supported in principle for implementation through other means.

ITSRR will introduce regulations including for data loggers that set out the expectations (or performance outcomes) required of industry.

The regulations will be developed on a national basis, through the National Transport Commission process, to ensure consistent application across the Australian rail industry.

Notwithstanding the expectation that industry will develop and maintain appropriate safety standards, ITSRR will retain the power to mandate such standards if the industry clearly fails to deliver satisfactory safety outcomes.

37. The standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally.

Supported in principle for implementation through other means. (See R 36)

Information from data loggers can be accessed to monitor for any incident or accident and can be accessed to monitor a driver's performance generally.

38. There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology.

Supported and being implemented.

The National Standing Committee of Transport endorsed the Australasian Railway Association working with operators and regulators, including RailCorp and ITSRR, to develop a national approach on communications systems, which has agreed minimum functionality requirements for train radio systems.

RailCorp plans to implement a digital train radio system. An objective of this system is for it to be interoperable with existing analogue radio systems. Because of the technical complexities associated with achieving inter-operability, this has been a longer-term initiative and the first stage of its implementation will commence in 2005.

39. Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way.

Supported.

RailCorp Network Procedures contain standardised communications procedures, which are in place across the NSW network.

ITSRR will introduce regulations including for communications that set out the expectations (or performance outcomes) required of industry.

The regulations will be developed on a national basis, through the National Transport Commission process, to ensure consistent application across the Australian rail industry.

40. All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols.

Supported.

41. All communications protocols must be strictly enforced by all accredited rail organisations.

Supported.

42. The ITSRR should audit the RMC to ensure communications protocols are being followed. The sanction for non-compliance with communications protocols should be identical to that in the aviation industry and involve immediate removal from duty. Any RailCorp employee not following communications protocols should be required to undertake further training. If, following return to duties after such training, the officer continues to fail to comply with communications protocols, that officer is not to be employed in communications related work.

Supported in principle and being implemented through other means.

ITSRR will take action against operators who fail to manage non-compliance with these protocols.

43. Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation.

Supported. As for R 39.

44. ITSRR should ensure, as a condition of accreditation, each of these recommendations is carried into effect and should audit against them to enforce compliance.

Supported. As for R 39.

45. The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols.

Supported and being implemented.

46. There should be interoperability of communications equipment between all trains operating on the New South Wales rail network.

Supported and being implemented.

Interoperability is defined in terms of the driver having one hand-set with interfaces to allow communications with the appropriate operating personnel. It does not imply a single all-users radio system.

The National Standing Committee of Transport endorsed the Australasian Railway Association working with operators and regulators, including RailCorp and ITSRR, to develop a national approach on communications systems, which has agreed minimum functionality requirements for train radio systems.

RailCorp plans to implement a digital train radio system. An objective of this system is for it to be interoperable with existing analogue radio systems. Because of the technical complexities associated with achieving inter-operability, this has been a longer-term initiative and. the first stage of its implementation will commence in 2005.

47. Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance.

Supported and being implemented.

48. All train drivers' defects reports should be entered by RailCorp into a computerised record and tracked to finalisation.

Supported and being implemented.

49. No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury.

Supported.

50. All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified.

Supported and being implemented.

51. The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp.

Supported and being implemented.

52. Maintenance plans on all trains should be revised annually.

Supported in principle for further review.

All maintenance plans are being reviewed. RailCorp will incorporate this recommendation in that review.

53. Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service.

Supported in principle for further review.

RailCorp is reviewing procedures and resources to rectify defects. RailCorp provides time for drivers of stabling trains to report any noted defect.

54. Random alcohol testing should be continued.

Supported.

55. Alcohol and drug testing should be mandatory for any train driver or guard involved in any accident or incident.

Supported.

ITSRR will review this recommendation as part of its ongoing involvement in checking Drug and Alcohol Programs of rail operators.

RailCorp currently tests randomly for drugs and alcohol and allows for drug and alcohol testing to be undertaken for safety-related accidents and incidents.

56. RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems.

Supported.

57. The ITSRR should develop standards for periodic medical examinations which include the following:

Supported and being implemented.

A National Standard for Medical Health Assessments for the rail industry is in place.

(a) all medical examinations of safety critical employees must contain a predictive element, including use of a cardiac risk factor predictions chart to assess risk of sudden incapacitation, and follow-up procedures, where indicated;

Implemented.

(b) medical examinations must be conducted by medical practitioners with an understanding of the duties and responsibilities of the safety critical employees being examined;

Implemented.

(c) a medical practitioner conducting such a medical examination should, with the employee's consent, have access to his or her medical history. If such consent is not given, the employee must be required to undertake a more exhaustive medical examination with specialist diagnostic procedures;

Supported.

ITSRR will submit this recommendation to the National Transport Commission (NTC) for consideration as part of the National Standard.

(d) all such medical examinations must be reviewed on behalf of the employer by an occupational physician;

Supported.

ITSRR will submit this recommendation to the National Transport Commission for consideration as part of the National Standard.

(e) appropriate follow up examinations, such as a stress ECG or examination by a cardiologist, must be arranged for any safety critical employee whom the occupational physician believes may be at risk of sudden incapacitation;

Supported in principle and being implemented through other means.

The standard requires follow-up examinations to be arranged for safety critical workers whom the examining doctor (*AHP) believes may be at risk of sudden incapacitation.

*Note The Health Assessment Standards refer to an Authorised Health Professional, who is not necessarily an occupational physician but is a doctor who has received the appropriate training.

(f) medical histories of employees should be monitored by an occupational physician to enable identification of any trends that may indicate a deteriorating state of health;

Supported.

ITSRR will submit this recommendation to the National Transport Commission for consideration.

(g) routine basic psychological screening, by means of a questionnaire such as the KlO questionnaire, should form part of periodical medical examinations;

Supported and implemented.

(h) medical standards should be reviewed at least every five years to ensure that recent advances in medical knowledge and technology are utilised; and

Implemented.

The national standard is to be reviewed every five years.

(i) periodic examination standards prescribed by ITSRR should take into consideration medical standards for safety critical rail staff prescribed elsewhere in Australia to ensure, so far as possible, uniformity of such standards.

Implemented.

58. RailCorp should establish a comprehensive safety document management system.

Supported.

59. The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff.

Supported and being implemented.

60. RailCorp should employ a Chief Safety Information Officer to manage the collection, collation information within RailCorp.

Supported in principle and being implemented through other means.

RailCorp has employed a Manager Information Systems within Corporate Safety Group whose role and accountabilities include these requirements.

61. RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace.

Supported in principle for further review.

RailCorp is reviewing options for providing all staff with the best and appropriate means of accessing safety documentation, including by electronic means.

62. The ITSRR should have permanent access to the RailCorp intranet.

Supported in principle for implementation through other means.

ITSRR has a number of means available to it to obtain information from RailCorp and other rail operators when required, including access to an operator's intranet where electronic safety information is maintained. This occurs for example during an audit of an operator.

63. The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system.

Supported and being implemented.

64. RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information.

Supported and being implemented.

65. Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR.

Supported and being implemented.

ITSRR and RailCorp will review the implementation of all the seven recommendations in light of the Waterfall Inquiry.

66. RailCorp should use its simulators in an interactive manner.

Supported and being implemented.

67. RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network.

Supported and being implemented.

68. Train driver and guard training should encourage teamwork and discourage authority gradients.

Supported and being implemented.

69. RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas.

Supported and being implemented.

70. Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills.

Supported and being implemented.

71. The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver's training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed.

Supported in principle for further review.

RailCorp is reviewing the current supervisory structure of train crewing in light of this recommendation.

72. The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia.

Supported in principle.

The Minister for Transport has written to the Commonwealth Minister for Transport to initiate negotiations on the appropriate mechanisms to enable the ATSB to undertake investigations referred to it by the NSW Government. This may require legislation in NSW via state referral of power to the Commonwealth.

73. The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales.

Supported in principle. See R 72

74. The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services.

Supported in principle. See R 72

75. All ATSB accident investigation reports should be made public.

Supported.

The NSW Government is advised the accident investigation reports are already published by this Commonwealth agency.

76. The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system.

Supported and being implemented.

77. The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales.

Supported in principle and being implemented through other means. See also R 64.

NSW already shares data with the ATSB and is working with other agencies in a project being managed by ATSB to expand the range of information which can be shared between all relevant agencies.

78. The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR.

Supported in principle and being implemented other means.

OTSI will be established as a separate agency independent of ITSRR, reporting directly to the Minister for Transport. OTSI will continue to conduct "just culture" investigations in NSW.

79. The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation.

Supported.

80. Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR.

Supported.

81. All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services.

Supported.

82. Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales.

Supported in principle for further review. See R 72.

83. RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including:

Supported and being implemented.

(a) the means whereby RailCorp proposes to ensure that all its operational, administrative and managerial staff consider the safety implications of any decision or action undertaken by them;

The RailCorp safety culture program will be reviewed to ensure compliance with this recommendation.

(b) the means whereby any distrust between management and operational staff is removed and replaced by a culture in which the whole organisation is motivated towards the safe conduct of its transportation activities;

The RailCorp safety culture program will be reviewed to ensure compliance with this recommendation.

(c) the means whereby RailCorp proposes to implement a just culture instead of a blame culture;

The RailCorp safety culture program will be reviewed to ensure compliance with this recommendation.

(d) the means whereby RailCorp proposes to establish and implement accountability and responsibility of individuals for the safety of the activities that they undertake;

The RailCorp safety culture program will be reviewed to ensure compliance with this recommendation.

(e) the means whereby RailCorp proposes to measure the safety performance of all individuals with accountabilities and responsibilities for safety, for the purpose of determining whether their level of safety performance is satisfactory;

The RailCorp safety culture program will be reviewed to ensure compliance with this recommendation.

(f) the means whereby the Board of Directors, the Chief Executive and the Group General Managers intend, by their actions and behaviour, to foster the development of a safety culture in the organisation;

The RailCorp safety culture program will reviewed to ensure compliance with this recommendation.

(g) the means whereby RailCorp proposes to reward employees for bringing safety issues to the attention of management, and the means whereby the management of the organisation proposes to track the safety issues raised, to ensure continual safety improvement;

The RailCorp safety culture program will reviewed to ensure compliance with this recommendation.

(h) the means, generally, whereby RailCorp intends to replace the present culture of on-time running with a culture encouraging safe, efficient and reliable provision of rail services;

The RailCorp safety culture program will reviewed to ensure compliance with this recommendation.

(i) the means whereby RailCorp proposes to ensure that communications protocols are followed by the employees of the RMC and all other employees engaged in safety critical work;

The RailCorp safety culture program will reviewed to ensure compliance with this recommendation.

(j) the means whereby RailCorp proposes to set safety targets for the reduction of incidents overall, and incidents in particular classes, and the means whereby the relevant information is to be kept and collated for the purpose of measuring safety performance in those areas;

The RailCorp safety culture program will reviewed to ensure compliance with this recommendation.

(k) the means whereby employees responsible for particular areas are rewarded for safety improvements in their areas of activity;

The RailCorp safety culture program will reviewed to ensure compliance with this recommendation.

(1) the means whereby RailCorp intends to integrate safety in all aspects and at all levels of the transportation activities which it undertakes;

The RailCorp safety culture program will reviewed to ensure compliance with this recommendation.

(m) the means whereby RailCorp proposes to train staff in processes of hazard analysis and risk management relevant to the particular activities that they conduct; and

The RailCorp safety culture program will reviewed to ensure compliance with this recommendation.

(n) the means whereby RailCorp is to integrate the management of safety in all aspects into the general management of its business undertaking.

The RailCorp safety culture program will reviewed to ensure compliance with this recommendation.

84. If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan.

Supported in principle.

ITSRR is reviewing the process used to develop the Plan. ITSRR will also review the Plan as submitted and monitor its effectiveness.

85. RailCorp's approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level.

Supported and being implemented.

86. RailCorp should integrate its management of occupational health and safety into its overall safety management.

Supported and being implemented.

87. Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues.

Supported and being implemented.

88. The RailCorp passenger containment policy must be abandoned.

Supported.

RailCorp will review and replace the current containment policy, in consultation with ITSRR.

The Commission recognised the complexity of determining appropriate policy and operational/technical arrangements for emergency egress from trains. Evidence to the Commission was that on some occasions passengers are best kept inside a train; in others they need to be able to escape.

An independent risk assessment of the alternatives to the current policy will be undertaken. This risk assessment will be consistent with recommendation 34, and the replacement passenger containment policy will be based on its results.

89. There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times.

Requires further detailed review, subject to the risk assessment referred to in R88.

90. All passenger trains must be fitted with an internal passenger emergency door release.

Requires further detailed review. See R 89.

91. All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate.

Supported and being implemented.

RailCorp has commenced a modification program to ensure all external emergency door releases do not require special keys or other equipment to operate.

92. The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary.

Requires further detailed review. See R 89.

93. The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard's compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard's compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train.

Requires further detailed review. See R 89.

94. The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train.

Supported.

95. All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words "Emergency Door Release".

Supported and being implemented.

96. All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms.

Supported and being implemented.

97. All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars.

Supported in principle and being implemented through other means.

RailCorp has produced a training DVD showing the location and operation of external emergency door release mechanisms. 500 copies have been provided to each of Fire Services, Police and Ambulance.

The very large number of emergency response personnel (including volunteer services) that may respond to a rail incident, means training of all personnel in the RailCorp Framework is unlikely to be achievable. Emergency Services will investigate with RailCorp extension of the DVD into a multimedia resource to improve the ability to educate wider numbers of emergency service workers.

98. All trains should have windows available through which passengers can escape.

Requires further detailed review. See R 89.

99. All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency.

Supported.

100. All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as "emergency services cut here".

Requires further detailed review. See R 89.

101. ITSRR should initiate and/or participate in the developmentof a national standard for crashworthiness of all passenger trains.

Supported.

102. RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management.

Supported in principle for further review.

RailCorp has developed and implemented a program of safety science training for senior managers (levels 2, 3 and 4). A comprehensive review of available formal qualifications in system safety management, including international practice, with an option of having RailCorp's training formally recognised.

103. RailCorp should establish clear safety accountability statements and reporting lines for all management positions.

Supported.

104. The RailCorp Board should establish independent external safety auditing processes to regularly audit and report to the Board on the implementation of an integrated safety management system by RailCorp and on safety performance generally.

Supported and being implemented.

105. The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers.

Supported and being implemented.

106. The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position.

Supported.

107. RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard.

Supported.

108. RailCorp should conduct internal and external safety audits to evaluate the adequacy of its safety management system and to ensure that any risk control measures are effective.

Supported and being implemented.

RailCorp's annual safety audit plan includes audits to evaluate the adequacy of its safety management system and risk control measures. The 2005 audit plan includes 4 external audits.

109. Following completion of any external audit, a corrective action plan to remedy any identified safety deficiencies should be developed by RailCorp, implemented and followed up within the business groups affected, to ensure appropriate and timely completion of the action plan, by a formal examination of the effectiveness of the controls put in place. Senior management personnel should certify that the corrective action plan has been implemented and is effective. Senior management personnel should be accountable for any such certification.

Supported.

110. A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should:

Supported.

(a) assign responsibility for particular aspects of the project to identifiable employees;

Supported.

(b) ensure that each person to whom such an aspect of the program has been assigned has the time and resources to undertake the tasks each is required to perform;

Supported.

(c) identify the period of time during which such persons are required to achieve the desired safety outcome for the particular aspect of the program;

Supported.

(c) specify a clearly defined scope of work to be undertaken, a schedule setting out when such work is to be completed, and institute a system of measuring whether or not the objectives have been achieved in the time specified; and

Supported.

(e) report to the Chief Executive of RailCorp on a monthly basis on each aspect of the program, and the Chief Executive is to report on a monthly basis to the RailCorp Board and to ITSRR, on the progress of each program.

Supported.

111. The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished.

Not supported.

The statutory obligation of the ITSRR Advisory Board to review and provide advice to OTSI in regard to accident investigations and any functions of the Chairman in respect of accident investigation will be removed but the ITSRR Advisory Board will be retained as a source of expert advice to ITSRR.

112. Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services.

Not supported.

The principal objective of ITSRR is to facilitate the safe operation of transport services in the state and to promote safety and reliability as fundamental objectives in the delivery of transport services. As such it makes a critical contribution to the transport portfolio.

ITSRR will be retained as an agency within the Transport portfolio, but its accountability and the responsibility of the CEO, and ITSRR's independence will be enhanced by providing explicit reporting requirements of ITSRR in the legislation and removing from legislation the requirement for the Advisory Board to review ITSRR reports.

113. The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales.

Supported in principle.

The Chief Executive of ITSRR administers the Government's rail safety legislation and provides advice on rail safety to the Government.

114. The ITSRR should publish guidelines to be followed by accredited organisations.

Supported.

115. The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR.

Supported.

116. The ITSRR should conduct field audits to satisfy itself that all accredited rail organisations conduct their activities in accordance with the safety management system on the basis of which each was accredited.

Supported.

117. Staffing arrangements for ITSRR should be reviewed by to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation.

Supported.

.

118. All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation.

Not supported.

Under the Rail Safety Act 2002, ITSRR has the right to require an operator to re-submit its Safety Management System (SMS), the central requirement of operator accreditation, at any time. This provides ongoing opportunity to review and check an operator's SMS as required rather than at a pre-determined frequency. Additionally, the National Rail Safety Accreditation Package (NRSAP) requires frequent audits of rail operators and evidence of continuous improvement in the operator's SMS.

119. The ITSRR, when considering a re-application for accreditation, should conduct a field audit of the organisation to ensure that it is carrying on its activities in accordance with the basis upon which it seeks accreditation.

Supported.

120. The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achieved by the implementation of all the recommendations contained in this report.

Supported in principle for further review.

ITSRR will continue to participate in the development of a national system for rail safety regulation.

121. A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide.

Supported in principle for implementation through other means.

ITSRR will introduce regulations that set out the expectations (or performance outcomes) required of industry.

The regulations will be developed on a national basis, through the National Transport Commission process, to ensure consistent application across the Australian rail industry.

122. RailCorp should establish an integrated safety management system which includes the following:

Supported.

The RailCorp Board has approved the safety strategic plan and the engagement of external experts to assist in the development of an integrated safety management system for RailCorp. The safety management system has been developed and will be implemented in 2005, consistent with the requirements of RailCorp's provisional accreditation.

(a) a formal performance management system, incorporating measurable safety accountabilities and responsibilities for each managerial position;

RailCorp will review its integrated safety management system against this recommendation to ensure consistency.

(b) defined safety accountability and responsibility statements for senior management;

RailCorp will review its integrated safety management system against this recommendation to ensure consistency.

(c) an effective means of reviewing and acting upon audit investigation and review findings;

RailCorp will review its integrated safety management system against this recommendation to ensure consistency.

(d) an effective system for managing audit and investigation findings, to ensure that

RailCorp will review its integrated safety management system against this recommendation to ensure consistency.

(e) criteria for recruitment and promotion of management staff, including safety management qualifications, experience and expertise;

RailCorp will review its integrated safety management system against this recommendation to ensure consistency.

(f) development of risk management procedures, including:

RailCorp will review its integrated safety management system against this recommendation to ensure consistency.

(i) analysis of the nature of the activities being undertaken;

(ii) identification of all potential hazards within those activities;

(iii) analysis of the nature of the hazard;

(iv) analysis of the risks of the hazard materialising;

(v) development of controls to mitigate the risk;

(vi) development of systems for monitoring the effectiveness of the controls to ensure that they are working;

(vii) development of a continuing program to enhance the development of safe practices at all levels of the organisation;

(viii) development of key performance indicators for safety performance by all persons in management positions;

(ix) development of a safety information data collection system which captures all hazards, occupational health and safety incidents, audit results, noncompliance findings and near miss reports;

(x) development of a system to arrange in priority order, on the basis of data and trend analysis, those safety deficiencies which require the most urgent attention;

(xi) design and implementation of communications protocols, including standard phraseology, with particular standard phraseology for emergency situations; and

(xii) development of training systems, based upon training needs analysis.

123. RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report.

Supported in principle and being implemented through other means.

RailCorp's draft integrated safety management system incorporates the substance of all 29 elements identified in the SMSEP.

124. The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established.

Supported in principle and being implemented through other means. See R 123.

125. The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including:

Supported.

(a) a statement as to whether or not the recommendation has been implemented and, if so, is working effectively; and

Supported.

(b) if the recommendation has not been implemented, the means by which the safety objective of the recommendation is otherwise to be achieved.

Supported.

126. The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR.

Supported.

127. The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report.

Not Supported.

The Government is confident that ITSRR has the capacity and competence to effectively monitor and review implementation of the recommendations arising from the Commission's Final Report. An additional independent auditor would duplicate the work of ITSRR and may cause confusion about which agency is the primary regulatory authority.