Thursday, November 23, 2023

Safety message: Human Factors in maintenance

In this safety message, ONRSR is highlighting some of the ways rail transport operators and rail infrastructure managers can apply a human factors lens to maintenance.

Safety message - Human factors in maintenance - Image - welder working.

Maintenance is a key part of asset management, requiring vigilance by those involved. Key maintenance-related tasks and activities include, but are not limited to:

  • inspection and assessment of rolling stock and rail infrastructure;
  • changeout or replacement of components;
  • installation or removal of components; and
  • relocation or requirements for rolling stock or rail infrastructure assets to be moved or shifted.

These activities are often conducted in difficult working conditions, such as restricted workspaces, low lighting and subject to time constraints. They may also involve communication and coordination between different areas of a business including with contractors. Maintenance is reliant on the performance of Rail Safety Workers (RSWs) and maintenance staff, and as with every maintenance activity, there are opportunities for issues or errors to arise e.g.

  • incorrect installation of components;
  • fitting of wrong parts;
  • electrical wiring discrepancies;
  • failure to detect a problem;
  • introducing a fault; or
  • not completing tasks fully or in the right order e.g. due to inadequate shift handover

If not managed, these issues can result in harm to workers as well as major incidents.

Thus, safe and effective maintenance involves the consideration of organisational, workplace/equipment/job and individual factors that can affect performance.

While not exhaustive and given the range of operational environments within the Australian rail industry, the following should be noted as key information and examples of good practices that an effective safety management system should cover to ensure human factors is considered in maintenance.

For simplicity, these have been split across seven key topics.

1. Rolling stock and rail infrastructure

Human factors applied to rolling stock or rail infrastructure minimises maintenance errors, the time required for maintenance, and the amount of maintenance required. Key aspects to consider include, but are not limited to:

  • labels on rolling stock or rail infrastructure, or related equipment, oriented the right way for the user.
  • gauges used to maintain rolling stock and rail infrastructure are in good condition, correctly calibrated, and readable from the distance they need to be read.
  • controls, buttons or levers on rolling stock and rail infrastructure etc., are secured and cannot be accidentally activated.
  • location of parts to be maintained or replaced can be easily seen and reached, providing the necessary safe space to maintain rolling stock or rail infrastructure.
  • rail infrastructure assets are placed outside the danger zone, where possible, so they can be maintained without needing to enter the danger zone.
  • disassembled assets, parts or related equipment are easy to reassemble, and in the correct order.

2. Tasks and activities

Human factors applied to maintenance-related tasks and activities ensures tasks RSWs and maintenance staff carry out do not lead to incidents. Key aspects to consider include, but are not limited to:

  • resources (e.g. staff, tools and equipment) are available to safely undertake maintenance tasks and activities.
  • roles and responsibilities are clearly defined to avoid confusion and/or duplication.
  • fatigue and overall work patterns managed to minimise fatigue and maximise vigilance.
  • safeworking and on-track worksite protection methods used in the rail corridor designed to account for mistakes and miscommunication.
  • frequency, schedule and location of maintenance tasks and jobs do not lead to fatigue.
  • tasks and activities are designed to account for variability e.g. variability in location, working conditions, resources and time constraints.
  • safety is not compromised due to conflicting maintenance tasks, activities, goals or priorities.
  • staff performing task and activities are suitably trained and competent to undertake the task safely and to the applicable standard.

3. Workplace environment

Human factors applied to the workplace environment minimises factors that negatively influence work performance and can result in errors. Key aspects to consider include, but are not limited to:

  • physical workloads and manual handling required is minimised or scheduled to reduce the risk of musculoskeletal disorders.
  • position and layout of tools and equipment is within easy reach and easily accessible when required.
  • environmental conditions are controlled to limit noise, vibration and manage the thermal environment (excessive heat and cold).

4. Documentation, systems and procedures

Human factors applied to maintenance-related documentation, systems and procedures (e.g. standards, work orders, inspection reports, recording systems, checklists, job cards) ensures they are accessible and usable for RSWs and maintenance staff. Key aspects to consider include, but are not limited to:

  • maintenance-related documentation and systems, including maintenance and assembly manuals, are easy to access, clear, accurate and complete.
  • end-users and human factors specialists are consulted when designing or reviewing maintenance-related documentation or systems.
  • human factors principles and methods are applied to the design of maintenance-related documentation, systems and procedures.
  • maintenance-related documentation and systems are easily followed, used, understood, and highlight personal and system safety critical information.
  • information regarding maintenance-related tasks and activities can be simply and easily recorded.
  • currency of information is maintained especially if two systems are used.
  • maintenance documentation and systems reflect current practice e.g. no gap between what the system or procedure says versus what is actually observed or applied in practice.

5. Shift handover and communications

Human factors applied to shift handover and communications ensures maintenance tasks and activities are adequately transferred between RSWs or people undertaking maintenance. Key aspects to consider include, but are not limited to:

  • adequate tools (e.g. systems, documentation, checklists, work instructions) are used to assist with handover including handover of:
    • asset status and incomplete maintenance tasks and activities;
    • maintenance issues that arise;
    • worksite protection arrangements and safe work requirements including any special precautions to be noted; and
    • status of the work and protection being afforded to the system or asset and to those working on it.
  • communication methods used (e.g., 3 way-communications) ensures the message is accepted, received and understood.
  • misunderstood verbal communication is minimised to account for miscommunication or interruption e.g. due to noise levels or inadequate equipment.
  • sufficient time is provided for handover.
  • contractors covered as part of handover and communication processes (particularly where maintenance teams are subcontracted).

6. Training

Human factors applied to training ensures RSWs and maintenance staff have the competence to safely carry out maintenance tasks and activities. Key aspects to consider include, but are not limited to:

  • minimum competency requirements for RSWs and people undertaking maintenance e.g. requirements for engineers, maintainers, contractors, inspectors.
  • training on functionality of systems used for maintenance tasks and activities
  • new systems or modified systems have the applicable training requirements built in as part of the roll-out
  • regular suitable refresher training is in place to ensure staff competencies for key tasks are maintained and assessed
  • basic human factors training on human error, physical constraints, workload, fatigue, and other performance influencing factors
  • non-technical skills e.g., training on decision-making, teamwork, situational awareness – see Rail Resource Management

7. Incident reporting

Human factors applied to incident reporting ensures maintenance issues are reported and then acted upon to prevent recurrence. Key aspects to consider include, but are not limited to:

  • staff are encouraged to report incidents.
  • systemic factors examined as part of incident investigations.
  • people undertaking incident investigation are competent and independent.
  • investigation findings are communicated to staff.
  • corrective actions adopt the hierarchy of controls and are implemented in a timely manner.
  • effectiveness and closeout of corrective actions are monitored and reviewed.


Following and adopting the advice provided in this document will assist in improving the operational safety of the rail network and have additional benefits including:

  • more efficient use of resources - with better programming of repairs and fewer reactive repairs
  • more efficient management of rolling stock and rail infrastructure assets leading to an improvement in the understanding of on-going resource requirements including future asset replacements
  • fewer overdue and non-compliant inspections or repairs
  • better risk-based management of responses to repairs.

In conjunction with the adoption of recommendations within this safety message, operators may benefit from reviewing their SMS. The following list includes, but is not limited to, those systems and procedures likely to be most relevant for review:

  • Management of change processes
  • Standards and procedures, work orders, inspection reports, recording systems, checklists configuration drawings and diagrams
  • Work instructions, service schedules, checklists, waivers, procedures, job cards, stage sheets, SWMS
  • Risk assessments
  • Competencies assessment and training processes
  • Incident and corrective action systems and procedures

Please see ONRSR Guideline - Safety Management System Guideline for more information.

The Safety Management System Guideline provides accredited rail transport operators, and those seeking accreditation, with guidance on the legislative requirements for safety management systems. It also details what ONRSR looks for when assessing safety management systems, and how to prepare a safety management system that complies with the legislative requirements.

All rail transport operators managing railway track may benefit from reviewing this guideline.

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

Last updated: Dec 14, 2023, 9:10:46 AM