Accident Incident Notifications

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Accident / Incident Notifications Investigations

• ARO Reporting Obligations
• Rail Safety Regulations
• Part 6
• Definitions
• railway accident or incident
• an accident or incident on railway premises that
  results in
• The death of a person
• Serious injury to a person resulting in that
  person requiring immediate medical treatment by a
  registered medical practitioner whin the meaning
  of the Medical Practice Act 1994
• A running line derailment of any unit of rolling
  stock
• A collision between any rolling stock and any
  person
• A collision between any rolling stock and any
  other vehicle, infrastructure, obstruction or
  object which resulted in significant property
  damage
• An implosion, explosion, fire or other occurrence
  which resulted in significant property damage
• A notifiable accident or incident.

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Accident / Incident Notifications
Investigations contd

• Notifiable accident or incident
• A railway accident or incident which the Safety
  Director has specified under regulation 42(1)
• Notifiable circumstances
• A circumstance, act or omission that resulted in,
  or had the potential to result in, the death or
  serious injury to any person, or significant
  damage to property and includes
• Any defect in, or failure of, any part of the
  rail infrastructure
• Any defect in, or failure of, any rolling stock
  or part of any rolling stock
• Any failure or breach of any rail operations
  practice, procedure or rule
• Any other circumstance, act or omission that the
  Safety Director has specified under regulation
  42(2) to be a notifiable circumstances.
• Note The Safety Director by specify an accident
  or incident notifiable circumstances to be
  notifiable.

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Duty to Notify

• Railway accidents or incidents
• Any ARO must notify the Safety Director
  immediately after becoming aware that a railway
  accident or incident has occurred.
• Within 72 hours give the Safety Director a
  record of the railway accident or incident in
  an approved form.
• Note Safety Director may extend this time in
  writing.
• Notifiable circumstances
• An ARO must notify the Safety Director in writing
  of a notifiable circumstance that has occurred in
  relation to the rail operations for which the
  operator is accredited.

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Reports

• Investigations
• Section 67 of Rail Safety Act 2006
• Regulation 45 of Rail Safety Regulations 2006
• Report to be prepared containing the information
  under sub-regulation (3)

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Reports contd

• Schedule 4 Investigation Reports

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Reports contd

• Copy of reports must be provided to Safety
  Director as soon as practicable after completion.
• ARO may be required to
• Conduct a more detailed investigation
• Provide further information
• Clarify certain matters contained in the report
• ARO have 7 days to comply with the above

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Monthly Reports (Regulation 46)

• A rail operator must for each calendar month give
  the Safety Director a report, in an approved
  manner detailing
• Total number of rail workers in the month
• Total number of pax journeys in the month
• Total number of track kilometres
• Total number of pax train kilometres
• Total number of freight train kilometres
• Report required within 10 days of end of the
  previous month
• The Safety Director may allow (b) above to be
  provide every 3 months
• Note Compliance with this Regulation is a
  condition of accreditation

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Exemptions (from Regulation 46)

• Tourist Heritage railways operators may apply
  to the Safety Director for an exemption from the
  requirement to submit a monthly report.
• Note You may have other occurrence reporting
  requirements Workcover etc.

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Duty to preserve accident or incident site
(Regulation 48)

• Accidents or incident notified under Regulation
  43
• Site can not be disturbed until directed by
• A transport safety officer
• The Safety Director
• except
• To protect the health or safety of a person or
• Aiding an injured person involved in a railway
  accident or incident or
• Taking action to make the site safe or to prevent
  a further occurrence of accident or incident or
• Allowing emergency services to manage the
  emergency
• Any s before we move on?

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Investigations

• Who can conduct a rail investigation in Victoria
• Commowealth ATSB DIRN
• Safety Director (PTSV) Rail Safety Act 2006
  (section 228ZB)
• Victorian Chief Investigator, Transport and
  Marine Safety Investigations Transport
  Legislation (Safety Investigations) Act 2006
• Victorian Police
• Victorian Coroner

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Conducting an Investigation

• References
• AS4292.7
• ARA CMC (Australia Code of Practice Man 6-2
  (Ver 1.0)
• Rail Safety Investigation
• Why investigate
• To determine what happened
• To determine how it happened
• To determine when it happened
• To determine why it happened
• Importantly To prevent similar events repeating

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Why a Code of Practice

• Provides procedure tools and examples to assist
  AROs in the conduct of an investigation
• The Code complies with the intent of AS4292.7
• Provides a structured systematic, consistent
  approach to investigation
• Focuses on systematic contributors to the
  occurrence

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What does AS4292.7 require?

• Necessary steps be taken to preserve evidence
• Occurrence needs to be reported
• IAW with procedures and
• Legislation
• The responsible authority (In the ARO) must be
  notified
• The severity of the occurrence assessed
• Appropriate level of investigation undertaken
• An investigator appoint and TORs prepared
• A final report produced

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Code of Practice Theoretical Framework

• The Core Principles
• Systems approach
• Just Culture philosophy
• Commitment to learning from failure
• A structured systemic and iterative process for
  gathering and analysing data
• Development of non-prescriptive recommendations
• Management to fair and independent investigation

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A Systems Approach

• Occurrences not normally one off events/isolated
• Almost always symptomatic of broader
  organisational issues
• Need to investigate beyond immediate events
• What else contributed to the event
• Significant organisation accidents
• Three Mile Island SUA March 79
• Human error
• Design deficiencies
• Component failures
• Chernaby
• Herald of Free Enterprise
• Londons Kings Cross Fire
• Clapton Junction Train Collision
• Waterfall in NSW

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Organisation are Systems

• A system is an assemblage / contribution of
  things or parts forming a complex or unitary
  whole
• Systems are made up of
• People
• Business, work processes, management frameworks
• Technology tools, equipment
• Physical and non-mode environment

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The Reason Model

• Developed by Prof James Reason late 1980s/early
  90s
• After research into accidents several industry
• Resulted in a simple explanation of key
  characteristics of an organisational accident
• Human Error
• Error is inevitable
• But focus is often on the sharp end only
• Errors occur throughout organisations
• By people often remote from the operation
• Active Failures
• Made by operational staff
• Latent Failures
• Systems/organisational failures
• Made by executives, designers, etc

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Organisation Model
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Contributing Factors

• Organisation Factors
• The management input
• Decision making, training, contractor management
• Workplace (local conditions)
• Psychological condition of people involved
• Task/environment characteristics/conditions
• Knowledge/skills
• Individual and/or team actions
• The active failures
• Errors
• A planned sequence of mental or physical
  activities fails to achieve its intended outcome
• Violations (intentional non-compliance)
• Techncial failures
• Items that dont come from operator error
• Broken rail
• O ring failure in the Challenger space shuttle
  (1986)

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Just Culture

• Human error is a normal consequence of human
  activity
• Just culture
• Is transparent and establishes clear
  accountability for actions
• It is not punitive or blame free
• Learning Organisation
• Dont waste the accident/incident

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The Investigation Process
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Level of Investigation

• Depends on severity and/or severity of the risk
  exposed

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Events and Conditions Chart
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Exercise - Berrburrum

• Look at the DVD
• Prepare an Events and Conditions Chart
• Prepare an Organisational Error Chart

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Berrburrum Events Conditions Chart
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Berrburrum Events Conditions Chart contd
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Questions