An accident, an investigation and a case for change

1
An accident, an investigation and a case for
change

• A rail safety campaign by the
• Australian Rail, Tram and Bus Industry Union
  (RTBU)

Roger Jowett IRSC, Denver 2008
2
Background

• Industry context South Australia (SA)
• Prior to 1998 ANRC was vertically integrated.
• In 1998 ANRC is privatised and sold in bundles
• Leigh Creek coal line electricity industry
  production,distribution,generation
• SA Rail Safety Act 1996 light hand

3
RTBU Rail Safety Campaign

• Australia wide review of rail safety in progress
• RTBU argues for review of the SA Rail Safety
  Act following
• Deaths, injuries, near misses
• Incidents and life expired infrastructure
• Rail companies investigate accidents

4
Australian Rail Network
5
Leigh Creek Line
High rail vehicle accident site September 2004
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RTBU Safety Demands

• Independent rail investigator-ATSB
• Systemic issues
• Role and responsibilities of the regulator
• National review of operating practices
• Train control procedures
• Working alone in remote locations

7
Hirail vehicle-post accident
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Accident site
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Accident Investigation Findings

• Large number of contributory factors
• 2 principal concerns
• Why did the hirail vehicle derail?
• The time taken to find the track inspector

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Investigation Report safety actions to be taken

• Safe working forms
• The vehicle
• Communications-contact lists
• Location devices
• Radio network control centres
• Overdue track occupancies

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Code of Practice Developed

• Code Management Company (RISSB) develops industry
  technical standards
• Development group
• Track managers/maintainers, rail regulators,
  vehicle manufacturers, rail operators, RTBU reps
• First meeting March 2005
• Guideline completed February 2006
• Australian Code of Practice
• Guideline for the safe operation of Road-Rail
  Vehicles

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Prosecution of Company

• Charged under OHS law
• Finding culpability of very high order
• Foreseeablity of risk serious injury/death
• Several means to reduce or remove risks
• Penalty of US48,000 with 20 reduction
• for early plea and contrition
• Another rail company fined US24,000 in early
  2008 for death of wagon maintainer

13
Wider issues raised

• Union studies of OHS fines found
• Fines actually imposed showed little relation to
  legislative provisions
• Value of life studies was variable
• Fines and sentencing outcomes were inadequate
• Deterrence ineffective
• Pervasive undervaluing of workplace deaths

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Wider issues raised(cont)

• Stronger framework required to improve safety
  outcomes
• Corporate crimes involving money attract
  significant fines and jail sentences apply
  similar principles?
• Relate fines to company turnover?
• Consider adoption of 2008 UK Corporate
  Manslaughter Legislation model?

15
Australian Transport Ministers to examine single
national regulator and separate investigator

• Options for single investigator
• Status quo enhanced status quo and single
  National Investigator
• 8 Governance principles

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Governance Issues

• Principles
• Independence
• Witness protection and confidentiality
• Transparency of public reporting
• Confidential reporting
• Current structures
• 8 jurisdictions
• 3 have dedicated investigator resources