Safety, Standards & Regulation

Sharing investigations – lessons for industry

In its monthly column, the Rail Industry Safety and Standards Board discusses the Sharing Investigations Forums scheduled in March and September 2020.

One of the forums RISSB co-ordinates on behalf of the rail industry in Australia and New Zealand is the Sharing Investigations Forum. The aim of this forum is to share lessons from a deep dive into incidents involving rail transport operators.

The ATSB has attended part of each forum and provided an analysis of, and lessons from, a rail incident. Or at the most recent forum, from an aviation incident. Featuring high on the agenda has been a presentation from a university around incident investigation and systems thinking.

To date, two forums have been held – one in Melbourne in 2018 and the other in Brisbane in 2019. Both Sharing Investigations forums were fully booked, and feedback was phenomenal with two further forums planned for 2020 – Sydney on 30th March at John Holland, Pyrmont and the second in Perth, likely to be held in September 2020 at Fortescue Metals Group in Perth.

Organisations that have presented and discussed an incident and the ensuing investigation into that incident have included: MTM, TasRAIL, ARTC, QR, Arc Infrastructure and Aurizon.

While there were many lessons shared, there were several common but critical lessons for industry that emerged from the in-depth discussions.

These include:

  • The need for clear, accurate safety critical communication (including the need to proactively monitor and demonstrate this).
  • The need to support identification of local risks (where workers do not perceive the level of risk, or the changing risk profile over time on site).
  • The importance of leadership from senior management/senior executives (response to incident is to ensure safety before continuing operations).
  • The benefits of reinforcing positive behaviours (through providing a just and safe culture).
  • Clarity on each person’s role and responsibility (ambiguity leading to assumptions that something was done).

RISSB is gathering lessons from these forums and turning them into a series of key lessons for industry that will be presented at the 2020 RISSB Rail Safety Conference in Sydney on 31 March and 1 April 2020.

In relation to communications, RISSB has worked with industry
to develop and publish a Safety Critical Communications Guideline (January 2018) and has since developed and is offering a Safety Critical Communications Course.

For more information about RISSB’s 2020 Rail Safety Conference, please visit conference-2020/

To view RISSB’s 2020 training and events, please visit