SWU 900 provides, inter alia:
· where work does not come within, or is not likely to come within, safety clearances, no protection is necessary and the procedures in this manual DO NOT apply. However, when any work is being performed close to the minimum safety distances, extreme care must be exercised;
· barriers may be provided within safety clearances as shown at [d] in this unit to protect work adjacent to the line and high visibility demarcation fencing or boundary tape may be used to define a work area.
(…)
Safe working unit 912 is entitled "Protecting employees working on or about the line when trains are not required to slow down or stop"
SWU 912 provides two methods of protection where employees can work on or about the line when trains are not required to slow down or stop:
i. the first method of protection is where employees are responsible for their own protection by looking out for trains themselves - 912[b] & [c]; and
ii. the second method is where a handsignaller(s) provides protection as determined by a work site supervisor - 912 [d] & [e];
SWU 912 further provides:
· when either of these methods is used all employees must ensure that they move to a safe place with their equipment and acknowledge the drivers locomotive whistle in sufficient time so that the driver does not need to reduce the speed of the train;
· when employees working on or about the line can safely look out for themselves and move to a safe place with their equipment without trains being required to slow down or stop, no other protection is necessary;
· when employees consider that they cannot safely look out for themselves, they must request a work site supervisor to determine the level of protection required. When employees working on or about the line cannot safely look out for themselves, a handsignaller must be provided to act as a lookout. The handsignaller acting as a lookout must warn all employees in the working party when a train is approaching. The warning may be given verbally or by a hooter, whistle or other approved warning device;
· there is no need to obtain train running information;
· employees may use light equipment or light machinery if required. However, the machinery or equipment must be light enough to be physically removed clear of the line by the employee(s) present;
· to determine how employees will be protected depends on a number of factors including the location, the reason for being on or about the line and the equipment being used.
(…)
Safe working unit 919 is entitled "Drivers duties when approaching people on or near the line and work sites"
SWU919[c] is entitled "Duties to be carried out when people are on or near the line" and provides, inter alia:
· Whenever you notice people or equipment on or near the line, or explode one detonator, sound the locomotive whilst to warn of your train's approach.
· When you observe the all clear handsignal, sound the locomotive whistle to acknowledge the handsignal.
· If you DO NOT receive an all clear handsignal from an employee at the work site, continue to sound the locomotive whistle until you receive an all clear handsignal.
· If you fail to receive an all clear handsignal and you consider that there is a possibility of the train striking a person or some equipment, make every effort to stop the train as soon as possible. DO NOT resume the journey until:
either you receive an all clear handsignal; or
you can see that the line ahead is unoccupied.
(…)
Safe working unit 922 ("SWU 922") is entitled "Work which effects automatic signals in electrified areas - Double lines only". SWU 922 requires, inter alia:
· the running times of those trains travelling on the line worked upon be established and monitored so that the work can be commenced and each stage of the work carried out without causing delays to the train service;
· the signallers at both ends of the section be informed of the details of the work. The details of the work are to be recorded in the train register book and the train controller advised of all details;
· the signaller controlling the entrance to the section must be advised which signal will be affected and is required to give verbal advice about which signal is affected to the driver of each train to travel through the section;
· an outer handsignaller is required to be positioned at each affected signal(s) and, in the event only 1 signal is placed at stop and the work site is 500 metres past the affected signal, an inner handsignaller is positioned 500 metres from the work site.
· handsignallers are required to regulate the safe passage of trains through the work site by causing trains approaching the work site on the line being worked upon to be stopped, the driver advised of the work site location, the work site advised of the approaching train and the driver of the train authorised to proceed through the work site when it has been established the work party has moved to a safe place. Communication is effected between the supervisor and the handsignallers by telephone or two-way radio.
(…)
27. Prior to 15 October 1998 persons carrying out track maintenance were not prohibited from standing in the space between adjacent live running railway lines (the six foot area) and portable plant was allowed to be stored in the area. It was considered by Mr Noble prior to the accident that both men and portable plant could be in the six-foot area whilst maintenance work was carried out on the up main railway line at 134.731 kilometres. Such a circumstance could result in "work on or about the line", that is, a work situation where employees, and portable plant could be located within 2.5 metres horizontally from the nearest rail of any running line. Mr Noble considered that SWU 912 [d] & [e] was implemented in combination with SWU 922 when track maintenance workers had less than 400 metres clear vision. On the date of the accident Mr Noble was of the mistaken belief that there was clear vision of 500 metres.
28. On 15 October 1998 the implementation of SWU 922 afforded protection to work sites 1 and 2 in regard to trains travelling in an easterly direction along the up main railway line. Both trains travelling on the up main railway line in an easterly direction towards work sites 1 and 2 and those engaged in work at work sites 1 and 2 were forewarned of the approach of trains travelling on the up main railway line by the flagmen positioned on the up main railway line.
29. SWU 922 did not provide protection to work sites 1 and 2 in regard to trains travelling in a westerly direction along the down main railway line. Maintenance workers at work site 1 took responsibility for their own protection in regard to trains travelling on the down main railway line by looking out for trains themselves. At the time of the accident the workers at work site 1 did not become aware of W529 until Mr Climan noticed it approaching at a point approximately 15 to 20 metres from the work site. Whilst the signaller at Mount Victoria Signal Box was aware of the nature and location of the works he was not required under SWU 922, or any other safe working unit, to inform trains travelling on the down main of the location of work sites 1 and 2 on the up main. The driver of W529 was not advised by the signaller at the Mt. Victoria Signal Box of the location of work site 1 and only became aware of the presence of workers on or about the line after the happening of the accident when informed by the train guard. Neither SWU 912 or SWU 922 required maintenance workers to inform themselves of the times trains were expected to travel on the down main railway line. SWU 922 was silent on this point and SWU 912 expressly stated "there will be no need to obtain train running information". On the relevant day Mr Noble, based on the fact he had informed the signalman at Mount Victoria about the nature and location of the works, assumed that trains travelling on the own line would be informed of the work being carried out at work sites 1 and 2 by the signalman at Mount Victoria. The signalman, however, did not similarly assume that he was to inform trains travelling on the down line of the work being carried out at work sites 1 and 2 because of the fact he was informed of the works by Mr Noble.
30. The implementation of safe working unit 912[d] & [e] in combination with safe working unit 922 would have afforded greater protection to maintenance workers at work site 1. A handsignaller acting as a lookout would have been charged with warning workers in regards to trains travelling in a westerly direction along the down main railway line. However, the implementation of SWU 912[d] & [e] was not mandatory and provided as an alternative to SWU 912 [b] & [c] where workers took responsibility for their own protection by looking out for themselves. On 15 October 1998 Mr Noble and Mr Hiley as the respective site supervisors decided that it was appropriate that the workers take responsibility for their own protection by looking out for themselves in relation to the down line. The eight (8) other workers at work sites 1 and 2 considered that they could safely look out for themselves and therefore did not make any request of either Mr Noble or Mr Hiley to provide further protection.
31. Mr Noble had carried out duties as an Infrastructure Worker 2B - supervisor since the early 1980's. He had not received adequate instruction or training in identifying potential risks or hazards associated with track maintenance insofar as he had not been trained to assess trains travelling on the adjacent down main as a risk or hazard on 15 October 1998. He was of the mistaken belief that maintenance workers had a view of over 500 metres and the Mount Victoria Signal Box was to warn trains travelling on the down main of the work site location.
32. Mr Noble received theoretical training in the 900 series manual and, whilst he had previously implemented SWU 912[d] & [e] and SWU 922 in combination, he had not previously received instruction or training in the operation of SWU 922 in combination with SWU 912. Mr Noble did not consider it necessary in the circumstances that prevailed on 15 October 1998 to implement SWU 912[d] & [e] because he mistakenly believed maintenance workers had 500 metres clear vision and believed trains were to be warned of the work location. He considered it practice that SWU 922 be implemented in the absence of SWU 912[d] & [e] when carrying out thermit welding work on tracks whilst trains travelled on adjacent tracks unless maintenance workers had less than 400 metres clear vision.
33. Rail Services Australia implemented the following measures subsequent to the accident:
a. on 16 October 1998 a written safety bulletin was issued followed by a written Amended Safety Bulletin on 23 October 1998 (…). The bulletins prescribed minimum arrangements, in addition to existing safe working procedures, required to be implemented in respect to all work on or about the track when traffic could operate on a line adjacent to the work site. The bulletins required, inter alia:
· visual separation of the work site and the adjacent line by the placing of demarcation tape or fencing between a work site and adjacent lines unless the work will take less than 30 minutes at a fixed work location;
· a handsignaller acting as a lookout placed adjacent to the work site in accordance with SWU 912 to warn of approaching trains. The handsignaller acting as a lookout is not to have any other duties;
· in circumstances where work continues for more than 30 minutes at a single location, an additional handsignaller is to be positioned 200 metres from the handsignaller acting as a lookout and place a detonator on the line 75 metres away between himself and any approaching train;
· where there is frequent traffic (ie. greater than 4 trains per hour), a person assigned the task of fixing detonators is to be provided; and
· where a work site supervisor consider that the above cannot be applied or may increase safety risks an exemption will be given only if a risk assessment of the site is documented and approved by the work site supervisors manager.
b. on 21 October 1998 a written memorandum was issued prohibiting the placing of materials, tools or equipment in the "six foot" (the space between two adjacent running lines). All material, tools and equipment were required to be placed in either the "four foot" (the space between the two rails of a running line) or cess of the track being protected. The written memorandum followed a verbal directive issued on 19 October 1998 (…).
c. document entitled "Pre-Work Briefing" and an associated briefing procedure was implemented. The document requires all persons working at a work site to attend a pre-work briefing. The briefing requires a discussion and understanding of the specific hazards related to the proposed work and control measures to be implemented, the completion of a work site protection plan by a work site protection officer and an acknowledgment by workers of the foregoing in signing a register (…).
34. Rail Access Corporation implemented the following measures subsequent to the accident:
(a) written Circular No. 470-99 entitled "Work site Infrastructure Works on the RAC Network" was developed "to provide greater separation of workers from operating train services" and the instructions incorporated in the document implemented on 23 August 1999 (…).
(b) In August 2000 Safe Working Unit 910 (SWU 910) was amended to reflect the substance of Circular No. 470-99 (…); and
(c) In August 2000 the method of protection whereby responsibility for their own protection by looking out for trains themselves in circumstances where trains were not required to slow down or stop was deleted from Safe Working Unit 912 (SWU 912) as an available means of protection (…).