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Accident Incident Notifications

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Title: 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.

4
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.

5
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

7
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

8
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

9
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.

10
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?

11
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

12
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

13
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

15
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

16
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

19
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)

21
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

22
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
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