The Australian Transport Safety Bureau too often hides behind a ‘no-blame’ policy and hesitates to label the true cause of rail incidents, a new paper suggests.
Rail engineer Ross Mitchell and solicitor Adam Bisits teamed up to put together the paper Lessons from Australian Derailment Investigations, which they presented recently at the International Heavy Haul Association Conference in Perth.
The paper finds some reports of derailments from the ATSB’s national railway accident investigation unit do not identify cause, or proper cause, when a cause seems fair – or even obvious – to identify.
Mitchell and Bisits believe investigators are too hesitant to label the cause of an incident, because they are instructed by legislation and the Bureau to not attribute blame, but they are also not explicitly instructed to label cause.
“The issue is that the ATSB looks at factors rather than causes,” Bisits told Rail Express.
“The ATSB hides behind the provision in their legislation that their job is not to distribute blame … well that’s fine, but you should still have to find a cause.”
The ATSB says on its website, “An ATSB investigation is purely aimed at determining the factors which led to an accident or safety incident so that lessons can be learned and transport safety improved in the future.”
“This is not practical and too general,” Mitchell and Bisits respond in their paper. “Rail operators and others want to know causes.”
Establishing cause is the dominant purpose of incident investigations in the United States, the United Kingdom, and in many other jurisdictions, the pair said in their presentation. But in Australian legislation – with one exception being Queensland’s – does not ask for cause.
Speaking with Rail Express, Bisits recalled one incident in 2006 where a bridge repairer at Geelong was seriously injured when a freight train collided with the elevated platform he was working on. The train had gone through a signalbox which should have instructed the driver to stop, but was instead cleared well before the train got there – a fact which Bisits tells Rail Express should have been clearly labelled as the ‘cause’ of the incident.
But because investigators could not identify whether the missing stop signal was caused by a single-person error, or a misunderstanding between multiple people, the report did not identify a “single decisive factor leading to the collision,” instead choosing to label a number of potential safety factors which contributed to the incident.
“That’s just not good enough,” Bisits said, adding in his presentation: “This does not show a proper regard for railway workers.”
Ross Mitchell is a Sydney-based rail operations and design engineer, who has consulted to engineering and mining companies. Adam Bisits is a Melbourne-based solicitor, who has for a long time had a ports and railway specialty.
The pair’s report also suggests investigations take too long to put together, and finds there is a possible lack of independence and conflict of interest, due to the Bureau working with a high level of anonymity.
“In Australia the actual investigators (assuming the commissioners are not personally investigating) are a mystery,” the report says, “including those who come from outside the public service, the special investigators, or consultants.
“Yet in Australia the pool of actual investigators is small and their past may have been with current important train operators or track owners.
“Thus there is a potential for ATSB investigations not to be completely independent, and for this to be hidden because the actual investigators are not publicly identified.”
I disagree. I attended the IHHA conference and remember that many attendees questioned the legitimacy of what was said. This presentation was dismissed by most as nonsensical.
Readers will no doubt realise that most investigation agencies such as RAIB, NTSB, TSB etc follow similar investigation protocols. They also take just as long to release reports – the big delays rest in rail operators providing records.