Wednesday, December 13, 2023

Safety Message: Altered Working Arrangements

ONRSR investigations and those conducted by other regulatory authorities have identified both good and poor practice when managing risks that arise when unexpected changes occur during railway operations.

Safety message - Digital re-creation: Altered working arrangements

When operations change from what is considered ‘normal’ operations (how the railway was designed to operate), they can enter a ‘degraded’ or ‘abnormal state’. If the events that lead to these states are not managed safely to return to ‘normal’ operations, the risk to safety can become uncontrolled, and may lead to an occurrence.

ONRSR has called these types of events Altered Working Arrangements.

However you define your Altered Working Arrangements, safety risks must be identified, assessed controlled and monitored – as required by the rail safety duties of the Rail Safety National Law (RSNL) (section 52) and the safety management system (SMS) requirements contained in sections 99 and 101.

In this safety message, ONRSR highlights some of the good practices with respect to managing safety risks during Altered Working Arrangements.

What we know works well

ONRSR has examined a range of rail occurrences, including those in other countries and has identified some common contributing factors to the successful management of Altered Working Arrangements:

  • Having systems and processes that clearly identify when and where an Altered Working Arrangement occurs.
  • Understanding the risks associated with transitioning from normal railway operations to an Altered Working Arrangement.
  • The SMS can manage the specific event that created the Altered Working Arrangement.
  • Rail safety workers involved in the management of the Altered Working Arrangement have the required skills and knowledge.
  • The management of Altered Working Arrangements is free from commercial, political and production pressures and influences.
  • Knowing when to stop operations.

For simplicity, these good practices are discussed under six key areas:

  1. Defining the different Altered Working Arrangement your operations may encounter
  2. Detecting changes between modes of operations
  3. Developing controls and response strategies for each mode of operations
  4. Roles, responsibilities and training
  5. Monitoring and review
  6. Safety focussed work culture

Defining the different Altered Working Arrangements your operations may encounter

This helps determine what could occur so that you know what to do when something unexpected does occur. Key aspects involved include, but are not limited to:

  • Identifying the range of Altered Working Arrangements (consider events that shift the operations from ‘normal’ operations to ‘abnormal’ or ‘degraded’ operations to an emergency). Past experience can assist with knowing the different Altered Working Arrangement events your railway operations may encounter. Remember these can be both planned and unplanned.
  • Safety limits and conditions for each Altered Working Arrangement event are defined e.g. minimum operating parameters, personnel available or staffing levels, actions to be taken and the time frames to take action (or other measurable criteria).
  • Identify controls, systems or components important to safety that must be functional for a given Altered Working Arrangement event.
  • Time or other measurable safety limits are defined stating how long railway operations can remain safely in a particular Altered Working Arrangement.

Detecting changes to operations

Detecting changes, such as moving from ‘normal’ to ‘abnormal’ or ‘degraded’ operations enables you to be ready to implement corresponding controls and prevents the situation from escalating. Key aspects involved include, but are not limited to:

  • Detecting when railway operations move to an Altered Working Arrangement (from ‘normal’ to abnormal or degraded) and being able to identify when these changes have occurred.
  • Systems and procedures or equipment (such as monitors and alarms) to enable detection of changes to your operations.
  • Triggers that are objective, measurable and clearly defined, and that if activated or breached, signal that the operation has changed.
  • When all else fails, systems should be able to detect the system is failing to manage the Altered Working Arrangement (becoming uncontrolled) and immediate action should be taken to stop the operations in a safe way, before they enter the emergency state.

Developing response strategies

Developing response strategies is about ensuring RTOs identify all the various events that lead to an Altered Working Arrangement and preparing controls so that risks are adequately managed. Key aspects involved include, but are not limited to:

  • Developing response strategies for each type of known Altered Working Arrangement (flooding, signal failure, late running, trespasser) that have clear response criteria and safety limits - e.g., what additional resources may be required and when operations must be suspended.
  • Establishing a range of controls that may be applicable to maintain safe railway operations for a given event e.g., speed restrictions, ceasing railway operations, detraining passengers, decoupling wagons, fixing faults, locking out points, increasing monitoring activities, putting in place additional controls, calling in additional drivers or staff, etc.
  • Time or other safety limits are specified as part of the response strategy to determine how long after the railway operations enter an Altered Working Arrangement controls are implemented, including setting limits for when the operations must be stopped.

Roles and responsibilities and training

These ensure everyone knows their role, what they are responsible for and can adequately implement required controls. Key aspects involved include, but are not limited to:

  • Training should be focussed on how rail safety workers identify the operations are entering an Altered Working Arrangement and the process for how the event should be managed, including how to access and implement the suite of response strategies.
  • Roles and responsibilities are established for implementing and monitoring controls associated with the response strategy - e.g., responsibilities for monitoring the ongoing risk associated with the Altered Working Arrangement, and making a decision to stop operations, are clearly defined.
  • Roles responsible for managing Altered Working Arrangements should be independent of production or commercial roles and must not be influenced by production or commercial pressures.

Monitoring and review

Operators should ensure that systems continue to adequately manage Altered Working Arrangements and continuously improve. Key aspects involved in monitoring and review include, but are not limited to:

  • Checking, monitoring, inspecting and testing controls used or implemented to ensure they function adequately.
  • Reviewing previous incidents to determine whether:
    • Definitions, safety limits or conditions for different Altered Working Arrangements are adequate.
    • Response strategies and controls implemented for a given Altered Working Arrangement are appropriate to manage risks.
    • Timeframes or safety limits set out in systems and procedures are adequate.

Safety focussed work culture

An RTO’s preparation and training can easily be undone by undue commercial, political or production pressures and influences. In order to avoid this, systems and procedures should also address “management bias” and promote a safety focussed work culture while managing an Altered Working Arrangement. Key aspects involved include:

  • Systems and procedures should be able to detect production/management priorities and pressures to keep services operating and take appropriate steps to ensure these pressures do not adversely impact safety.
  • Operational personnel should be appropriately supported and supervised during the Altered Working Arrangement to ensure they are following the response strategy and making decisions based on safety, not production.
  • Ideally, a decision to stop or continue operations should not be made in isolation and should involve the support of senior management.
  • Senior management should openly and actively support the safe management of all Altered Working Arrangements, including all decisions to stop operations. To be clear, senior management should be regularly promoting safety above production to maintain a safety focussed work culture.

Further information on altered working arrangements can be found here

You can also watch the ONRSR Digital recreation #7 - Altered Working Arrangements (click at right).

A comprehensive collection of ONRSR Safety Messages is available to view here.

Last updated: May 27, 2024, 2:28:45 PM