Atsb transport Safety Report


Emergency management exercises



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Emergency management exercises


Number:

RO-2013-005-SI-11

Issue owner:

Queensland Rail Limited

Operation affected:

Rail - All

Who it affects:

All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.

Safety issue description:


Emergency management simulation exercises to test the preparedness of network control staff, train crew, and station customer service staff to respond cooperatively to rail safety emergencies had not been undertaken in accordance with the Queensland Rail Emergency Management Plan

Response to safety issue by Queensland Rail


Queensland Rail has conducted two cross-business emergency exercises including a tunnel evacuation in October 2013 and a strategic desktop exercise in December 2013. Representatives from operations, customer corporate and the emergency services were participants in both exercises. The Emergency Management Unit has implemented site specific Emergency Preparedness and Response Plans at all SEQ stations including the development of localised incident management teams for local exercises. Short emergency scenario exercises have been developed for local managers to encourage cross-business participation.

Queensland Rail has developed a single integrated process to address communication protocols within the network control centre and between the network control centre and an emergency site.

Queensland Rail provided the ATSB with a copy of the Emergency Exercise Schedule for years 2013 and 2014. The schedule demonstrates the inclusion of internal business units and personnel working with external agencies for rail safety and security desk top and field type exercises. The schedule is regularly reviewed and adapted in accordance with operational requirements based on identified and emerging risks.

ATSB comment in response:


The ATSB is satisfied that the action taken by Queensland Rail addresses this safety issue.

Action status: Closed


Post emergency debrief and findings


Number:

RO-2013-005-SI-12

Issue owner:

Queensland Rail Limited

Operation affected:

Rail - All

Who it affects:

All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.

Safety issue description:

The Queensland Rail internal emergency debrief following the Cleveland station collision identified issues related to working with external agencies but did not address critical communication shortfalls within train control and between train control and the staff located at the Cleveland station accident site.

Response to safety issue by Queensland Rail


Queensland Rail has implemented an Emergency Preparedness and Response Plans (EPRP) for all City Network Stations and continues to implement an integrated process for addressing communication protocols during emergence incident response.

Lessons learnt during incident debriefing will be captured in Queensland Rail’s newly developed Governance Risk and Compliance (GRC) system which will replace a number of existing systems currently capturing this information.



ATSB comment in response:

The ATSB notes that Queensland Rail is developing a Governance Risk and Compliance system and that this system aims to address communication shortfalls between staff located at network control and accident sites.


ATSB safety recommendation to Queensland Rail


Action number: RO -2013-005-SR-023

Action status: Monitor

The Australian Transport Safety Bureau recommends that Queensland Rail undertake further work to address this safety issue.

Occurrence notification standard and guideline


Number:

RO-2013-005-SI-08

Issue owner:

The Office of the National Rail Safety Regulator

Operation affected:

Rail - All

Who it affects:

Railway safety regulators and railway network owners and operators responsible for the classification and review of railway occurrence notifications.

Safety issue description:


The national rail occurrence standard and guidelines (ON-S1/OC-G1) do not include significant train wheel slip/slide occurrences as a notification category/type which has the potential to lead to rail safety regulators being unaware of significant and/or systemic safety issues related to wheel/rail adhesion. [Safety issue]

Response to safety issue by the Office of the National Rail Safety Regulator


The ONRSR agrees to review and include more explicit guidance on slip-slide events in the appropriate existing categories of the ON-S1 Standard and OC-G1 Guidelines.

The ONRSR will furthermore consider the need to establish a specific category for slip-slide occurrences as part of the national data strategy review.


ATSB comment in response:


Action status: Closed


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