9 years on locos watching it happen. You don't have to be a genius to realise multiple investigations by the ATSB, PTSV and OTSI have recurring themes, suggesting there is an issue.
and there will always be recurring themes, because people are people.
There becomes a finite point when the sheer cost of implementing engineered systems outweighs their benefits.
I am sure that the same arguments were had over the introduction of driver safety systems (vigilance control) albeit that their was was no internet to open the discussion up.
However, big business is in the business of making profits, watch the arguments that are occurring in America over single crewing, look at the arguments that occurred in Aus over the same issue. I was stood down in NSw over the 2 man crewing dispute for removing brakevans, so have a history in this.
However read any investigation report from Australia in the last 15 years, we seem to have gone down the path of having an investigation, but rather than making findings that require action, there are recommendations etc.
Read the statement at the end of an ATSB report "
Purpose of safety investigations
The object of a safety investigation is to identify and reduce safety-related risk. ATSB
investigations determine and communicate the factors related to the transport safety matter being
It is not a function of the ATSB to apportion blame or determine liability. At the same time, an
investigation report must include factual material of sufficient weight to support the analysis and
findings. At all times the ATSB endeavours to balance the use of material that could imply adverse
comment with the need to properly explain what happened, and why, in a fair and unbiased
Developing safety action
Central to the ATSB’s investigation of transport safety matters is the early identification of safety
issues in the transport environment. The ATSB prefers to encourage the relevant organisation(s)
to initiate proactive safety action that addresses safety issues. Nevertheless, the ATSB may use
its power to make a formal safety recommendation either during or at the end of an investigation,
depending on the level of risk associated with a safety issue and the extent of corrective action
undertaken by the relevant organisation.
When safety recommendations are issued, they focus on clearly describing the safety issue of
concern, rather than providing instructions or opinions on a preferred method of corrective action.
As with equivalent overseas organisations, the ATSB has no power to enforce the implementation
of its recommendations. It is a matter for the body to which an ATSB recommendation is directed
to assess the costs and benefits of any particular means of addressing a safety issue.
When the ATSB issues a safety recommendation to a person, organisation or agency, they must
provide a written response within 90 days. That response must indicate whether they accept the
recommendation, any reasons for not accepting part or all of the recommendation, and details of
any proposed safety action to give effect to the recommendation.
The ATSB can also issue safety advisory notices suggesting that an organisation or an industry
sector consider a safety issue and take action where it believes it appropriate. There is no
requirement for a formal response to an advisory notice, although the ATSB will publish any
response it receives.
there is talk of safety advisory notices, however these are often issued by the Regulator ( see safety alert on dual gauge point following XPT derailment)
We operate in a highly regulated industry, however how we control risk is markedly different, in Sydney the chosen path was fitting of train stops to mitigate against the effects of a SPAD, other states implemented early versions of a positive train control.
For example, a few weeks ago I was sitting in a plane at Sydney waiting to fly to Adelaide, we were sitting on the cross runway waiting for a path to take off, there was a minor delay whilst several planes, including a jumbo, landed, then we received permission, entered the runway and departed.
Funnily enough there are no hard barriers to safeguard this movement, in railways we have a variety of barriers, including, but not limited to, 2 signal protection, conditional clearing, train stops, positive train control, etc etc etc.
Yet still we breach the integrity of the block ahead, it does not happen often at an airport, what are the differences? 2 up front? monitoring of communication logs, a more draconian discipline policy?
For many years we have had a 'just culture' no blame policy where it is a bit 'its not my fault i stuffed up, its your fault for not training me'
does this need to change, do we need to sack those who transgress rules?