A lack of clear safety instruction has been labelled a more significant factor than the presence of methamphetamine in the system of a rail worker who was killed by a passenger train north-east of Perth in 2015.
A Public Transport Authority (PTA) track worker died after he was hit at a level crossing by an A-series train operating between Perth and Midland on the Transperth passenger network, just after 10.30am on February 10, 2015.
According to the final incident report, released this month by the Australian Transport Safety Bureau, the man was within the rail corridor with another maintenance worker, inspecting a pedestrian level crossing gate, when he turned around and began to cross the railway.
Despite an earlier warning from one of his colleagues of an oncoming train, the sounding of the train’s horn by its driver, and a further verbal warning from a colleague as he began to cross the track, the worker appeared to be unaware of the train’s approach prior to his death, the ATSB reported.
A toxicology report identified the presence of methamphetamine and amphetamine in blood and tissue samples taken from the man in a post mortem examination.
While the Bureau did note that the use of stimulants such as methamphetamine is associated “with a range of neurocognitive effects in humans that may affect performance,” it decided “it was not possible to determine whether this contributed to the incident.”
Instead, the ATSB identified a series of safety system errors as major contributing factors in the fatal collision.
“The PTA maintenance workers had not implemented any form of track worker protection at the site,” the Bureau wrote.
“This was partially due to the PTA not having documented instructions specifying the level of protection required, preferring that track workers make their own assessment based on their knowledge of the Network Rules.
“The ATSB found that, under these arrangements, track workers could make an incorrect assessment, placing themselves at a greater risk of being struck by a train.”
The key issues on the day of the incident seemed to arise from PTA’s position that maintenance workers are trained and competent to determine the appropriate level of worksite protection for any given job.
On the day of the incident, the Bureau said, the team of three workers should have assigned a lookout, to observe the site and warn other workers to leave the danger zone (within 3m of the outer rail on either side of the track) as trains were approaching.
The Bureau said no lookout had been assigned and no discussion had taken place regarding worksite protection – a discussion which is supposed to be led by the team’s assigned protection officer, who in this case was the man eventually killed by the oncoming train.
“In this occurrence, the ATSB found that the protection officer had not discussed the worksite protection method with the train controller or the contractors prior to commencing work,” the ATSB found.
“It was evident that the role of a lookout had not been allocated, as all three track workers continued to be engaged in maintenance tasks.
“At the time of the collision, the protection officer was involved with maintenance tasks rather than the assigned role of protection officer.”
In response to the incident, the PTA issued a safety alert stating all employees required to work within, or likely to enter, the danger zone must be protected from rail traffic.
The safety alert reinforced the requirements of lookout protection.
PTA has also introduced a new system of safe-working accreditation for work of this type, replacing the existing accreditation with “a more rigid tier-based process”.
“The ATSB is satisfied that the actions taken by the PTA significantly reduces the safety risk, and when combined with completion of the additional training should fully address this safety issue,” the Bureau concluded.