INQ121

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.

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

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 invest

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.

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.

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.

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.

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

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.

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

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 examinati

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

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.

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.

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

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.

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.

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

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

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

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.

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 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.

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.

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

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.

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.

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

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

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

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.

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.

RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp.

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

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

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.

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.

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.

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

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

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.

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 occurre

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.

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.

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

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

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

RailCorp should use its simulators in an interactive manner.

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

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