Susan McCarrey, National Rail Safety Regulator v Sydney Trains

Proceedings 2018/183611 (the Work Charge)

1. The offender has pleaded guilty to an offence that as a rail transport operator who had a duty under s 52(1) of the Rail Safety National Law (NSW) to ensure, so far as is reasonably practicable, the safety of its railway operations, it failed to comply with that duty on 18 June 2016 and the failure to comply with that duty exposed Charles Lagaaia and Adam Weston (the Signals Team) to a risk of death or serious injury contrary to section 59 of the Rail Safety National Law (NSW).
2. The Amended Summons filed on 13 May 2019 alleged that the offender failed to take one or more of the following reasonably practicable measures which would have eliminated or minimised the risk: 1. Conducting a worksite briefing and/or induction in which Mr Lagaaia and Mr Weston were told about the worksite, the locations at the worksite that were safe, the safety measures that had been implemented, the nature and extent of any protection that had been provided, and the parts of the worksite that were and were not protected against the risk, before remaining at the site or undertaking any work at the site; 2. Having a work rule or instruction that required worksite supervisors not to permit anyone to be at a worksite or to perform work on or near railway lines unless the worksite supervisor has verified that the person received the worksite protection pre-work briefing from the protection officer; 3. Having a work rule or instruction that required the protection officer to show all workers the diagram or map of the worksite protection arrangements as part of the worksite protection pre-work briefing; 4. Having a system of work that required the placing of physical signs, tape, barriers or other effective controls to manage the risk.
3. This charge arises from an incident on 18 June 2016 when Charles Lagaaia was struck and killed by a passenger train whilst carrying out works on the track at Clyde NSW (the Work Charge).

Proceedings 2018/183633 (the Preparation Charge)

1. The offender has also pleaded guilty to an offence that as a rail transport operator who had a duty under s 52(1) of the Rail Safety National Law (NSW) to ensure, so far as is reasonably practicable, the safety of its railway operations, it failed to comply with that duty on 17 and 18 June 2016 and the failure to comply with that duty exposed Karl Joseph, George Wakim, Viet Do, Neil Constantinou, Salah Zein and Joseph Levay (the Civil Team) to a risk of death or serious injury contrary to section 59 of the Rail Safety National Law (NSW).
2. The Amended Summons filed on 13 May 2019 pleaded that the offender failed to put in place any recognised applicable method of work on track protection in accordance with NWT 300 Planning Work in the Rail Corridor.
3. This charge arises from the exposure of the Civil Team to risk between 10.30pm on 17 June 2016 and 12.10am on 18 June 2016 (the Preparation Charge).

Background

1. The parties presented an Agreed Statement of Facts and this material is summarised below, supplemented by the explanation of technical matters provided by counsel in oral submissions.

Sydney Trains

1. At all relevant times the offender: 1. was a body corporate constituted under the Transport Administration Act 1988; 2. was an accredited Rail Transport Operator under Part 3 of the Law, and the Rail Infrastructure Manager in respect of all relevant railway track.

The location of the incident

1. The incidents occurred on and adjacent to the up main line (that is, a running line on the Sydney Trains network travelling in the direction of Sydney Central Station) in the area controlled by the signaller at Clyde NSW.
2. The up main line was operational at all times relevant to the charges. Regular passenger service trains were travelling along the up main line. The speed limit on that line was 80 kph.

The points

1. The incidents involved two sets of points. Trains could be diverted off the up main line, at the 63 points, to the up storage siding and to the down through road and Pacific National shunting yard via the 64 points.
2. The 64 points comprised a double-ended set of points with an "A" and a "B" end and a short portion of track in the centre. Collectively, this was called the "64 points crossover".

The works

1. On the evening of 17 June 2016 the Civil Team was required to replace rotten sleepers under the tracks at the 64 points crossover at Clyde, NSW.
2. The Civil Team included a protection officer, Mr George Wakim, who was an employee of the offender nominated on the day to be responsible for managing the rail safety component of worksite protection, and primarily keeping the worksite and workers safe.
3. The Signals Team was required to support the Civil Team in respect of, inter alia, signalling and associated support systems. The signals team comprised two workers, Mr Adam Weston and Mr Charles Lagaaia. The Signals Team was led by Mr Weston.
4. Prior to the work commencing late on 16 June 2016, 63 points had been booked out of use (i.e. taken out of service) by a signals electrician, Mr Tony Parker and locked in normal position with points clips pursuant to an Infrastructure Booking Authority (IBA) to prevent rail traffic accessing 64 points. This prevented trains from diverting off the up main line at 63 points toward 64 points where the civil works were to take place.
5. Mr Wakim was aware that 63 points had been booked out of use and were clipped and locked in the normal position. Mr Wakim, aware that this IBA had been taken out, subsequently used it as a safety measure to protect the rail safety workers who would be working at the 64 points crossover.
6. An IBA is not one of the work on track authorities prescribed for carrying out work in the Danger Zone. It is used to tell Signallers that infrastructure is removed or returned to service.
7. The role of the Signals Team included booking back in 63 points after the Civil Team's work at 64 points was completed. The Signals Team was responsible for returning the 63 points to service.

The preliminary works

1. At approximately 10.30pm on 17 June 2016 Mr Wakim conducted a pre-work briefing with the Civil Team. The members of the Civil Team signed the pre-work briefing document indicating inter alia that they; 1. had been inducted to the site; and 2. had been briefed on the contents of the Worksite Protection Plan. The Signals Team was not present at the pre-work briefing and did not sign the briefing document.
2. Preliminary works were then undertaken by the Civil Team which included the removal of dog spikes from timber sleepers on the tracks.
3. No protection authority was sought from Sydney Trains at the commencement of the preliminary works. Tracks in the vicinity of the worksite remained operational, including the down through road, on the opposite side of the worksite to the up main line.

The first Track Occupancy Authority (TOA)

1. At approximately 12.11am on 18 June 2016 a Sydney Trains Track Occupancy Authority (TOA 35) was issued in respect of the worksite at 64 points by the Clyde signal box signaller, Mr Danny Day, at the request of Mr Wakim. Mr Day was also an employee of the offender.
2. TOA 35 gave authority to occupy: "Clyde end of storage siding to down thru (sic) road [...] between 23L signal and 24R signal". for work to be performed to: "replace timbers".
3. TOA 35 recorded that Mr Wakim had read back the details of the TOA to Mr Day.
4. As a result of the TOA, signals 23L and 24R were turned to red, thus prohibiting rail trail traffic in the 64 points area. TOA 35 protected 64 points. 63 points on the up main line were not within the area protected by TOA 35.
5. Until TOA 35 was issued, the six members of the Civil Team were at risk of death or serious injury. Such risk existed between 10.30pm and 12.10am.

The Fatality

1. At approximately 5.36am on 18 June 2018, Mr Weston and Mr Lagaaia attended the worksite at 64 points to return those points and 63 points to service once the work by the Civil Team was completed. The task of returning the points to service included a worker removing clips and contacting the signaller by telephone to confirm the points were operational.
2. Prior to undertaking any work at 63 or 64 points Mr Weston and Mr Lagaaia: 1. did not undergo any substantive pre-work briefing or induction to the worksite; 2. did not sign the pre-work briefing document that had been signed by the civil team; and 3. were not shown a copy of a diagram clearly showing the part or parts of the worksite that were protected by the TOA.
3. TOA 35 expired at 6.02am. TOA 36 was then issued by Mr Day at the request of Mr Wakim. The limits of TOA 36 were identical to TOA 35. It covered 64 points but not 63 points.
4. Following the completion of the civil works at 64 points, Mr Weston removed the clips from 64 points, and returned them to service in consultation by phone with the signaller Mr Day.
5. Mr Weston and Mr Lagaaia then attended 63 points on the up main line to remove the clips and return those points to service. At 6.08am, while Mr Weston was on the phone to Mr Day, Mr Lagaaia was in the process of removing the points clips. While doing so he was struck by a passenger train service, which was travelling along the up main line. Mr Lagaaia was fatally injured.

The Offender's Evidence

1. Mr Stewart Mills swore an affidavit on 5 July 2019. Mr Mills holds the position of Executive Director, Engineering and Maintenance Directorate at the offender. This affidavit ran to 228 pages with annexures. It was not the subject of any challenge and I accept all of the evidence given by Mr Mills, and take it into account.
2. At the time of the incidents, Mr Mills was responsible for planning and managing the maintenance of rail infrastructure across the Sydney Trains rail network and had had approximately 30 years of experience in the rail industry.
3. I adopt the following summary of part of the evidence of Mr Mills, provided in the written submissions by senior counsel for the offender: "Sydney Trains is a large, complex enterprise as described by Mr Mills in paragraphs [12] to [27] of the Mills Affidavit. Sydney Trains is responsible for the maintenance of approximately 1,643 kilometres of track, maintains over 2,191 electrical and diesel carriages, operates 1.2 million trips each weekday, to and from more than 380 railway stations which it maintains, and employs approximately 10,000. The Engineering and Maintenance Directorate employs 4,000 of those people. In the 2018/19 financial year, contract workers completed a total of 316,500 hours of worksite protection work."
4. Mr Mills contacted the Chief Executive of Sydney Trains, Mr Howard Collins immediately on being notified of the Incident and went to the Incident site, speaking with workers involved in the Incident and managers on site.
5. A few hours after the Incident occurred, a meeting was held by Mr Mills with approximately 100 workers present, where Mr Mills spoke to the workers about the Incident and explained to them that the managers were available to provide support to the workers.
6. Mr Mills regarded it as his duty to support Mr Lagaaia's family and attended Mr Lagaaia's family home on the afternoon of the Incident to express Sydney Train's sorrow and sympathies to members of Mr Lagaaia's family.
7. The offender has Network Rules and Network Procedures forming part of its Safety Management System. To achieve the objectives of the Glenbrook Report, Sydney Trains' safeworking units were deliberately re-drafted to focus on what must or may be done rather than to expressly prohibit specific actions in carrying out work safely.
8. The Network Rules and Network Procedures for work in the rail corridor mandate the ways to plan and achieve the separation of rail traffic from people working on or about the track. NWT 300 Planning Work in the Rail Corridor (NWT 300) prescribes the rules for planning work within the rail corridor and assessing safety of the work and its potential to intrude on the danger zone. It requires a worksite in the danger zone to have a Protection Officer to manage the rail safety component of worksite protection which includes briefing workers about worksite protection and safety measures and keeping records of the method used for working safely on track and the protection arrangements in place. NWT 300 also requires workers in the rail corridor to wear approved high-visibility clothing.
9. The Protection Officer must select one of the five work on track methods to avoid the risk of collision with a train when planning work in the danger zone. Formal authority is required from a Network Control Officer to take possession of a portion of a track.
10. On the night of the incident, the Civil Team comprised five workers including the Protection Officer, Mr Wakim and the Signals Team comprised two workers. Each of these workers held a current rail safety worker competency, authorising them to carry out work on track. Mr Wakim held a Protection Officer Level 2 competency. A Protection Officer Level 2 competency can assess all risks associated with work.
11. On the night of the Incident, the preliminary works should have been planned and undertaken in accordance with NWT 300 and a safety assessment of the appropriate method of protection should have been carried out, with a worksite protection plan detailing the protection arrangements implemented after a pre-work briefing had been conducted. Only LPA and TOA work on track methods were suitable.
12. The affidavit of Mr Mills shows that even before the events leading to the charges, Sydney Trains had a comprehensive rail safety management system. There was no explanation why it was not followed on the night.
13. The offender has continued to improve its safety system. Some of the further steps which have been taken were specific responses to the incident. The evidence demonstrates a strong commitment to safety on the part of the offender and the investment of much time and expense in the continuous improvement of rail safety. Since there was no challenge to the evidence of Mr Mills, I adopt the summary of the steps which have been taken, contained in paragraph 7.4(c) of the written submissions of senior counsel for the offender: "(i) Corridor Safety Centre: see [94] to [104] of the Mills Affidavit; (ii) Protection Officer coaching and mentoring: see [105] to [115] of the Mills Affidavit; (iii) Safety Focus Program: see [116] to [119] of the Mills Affidavit; (iv) Safety Focus Sessions: see [120] to [129] of the Mills Affidavit; (v) Safety Culture Program: see [130] to [136] of the Mills Affidavit; (vi) Protection Officer Selection and Training Project: see [137] to [160] of the Mills Affidavit; (vii) Signal Key Switch Project: see [161] to [170] of the Mills Affidavit; (viii) Safety Critical Communications Enterprise Wide Program: see [171] to [175] of the Mills Affidavit; (ix) Maintenance Access Planning Project: see [176] to [180] of the Mills Affidavit; (x) ATRICS ASB: see [181] to [183] of the Mills Affidavit; (xi) Use of other technology: see [184] to [186] of the Mills Affidavit; (xii) Human factors: see [187] of the Mills Affidavit; (xiii) Changes to the Network Rules and Network Procedures: see [188] to [195] of the Mills Affidavit; and (xiv) Actions taken at Clyde Network Base: see [196] of the Mills Affidavit."
14. In his affidavit Mr Mills expressed remorse and regret that the offender breached the Law. He acknowledged and regretted the impact on the family of Mr Lagaaia, his wife, children and grandchildren. He also expressed regret for the impact the incident had on the workforce generally. He annexed to his affidavit documents evidencing remorse and regret.
15. Mr Mills attended Mr Lagaaia's funeral service and was one of the people who addressed the congregation. A memorial to Mr Lagaaia was installed by the offender at Clyde Network Base. Memorial Services are held each year. Support and counselling was provided by the offender to employees of the offender, including those at Clyde Network Base. I accept those expressions of remorse and regret as entirely genuine.

Consideration

1. I have had regard to the purpose and objects in s 3 of the Law and the purposes of sentencing set out in s 3A of the Crimes (Sentencing Procedure) Act 1999.

Objective seriousness of the offence

1. The proportionality principle requires that a sentence should neither exceed nor be less than the gravity of the crime having regard to the objective circumstances: Veen v The Queen (No. 2) [1988] HCA 14; (1988) 164 CLR 465 at 472, 485-6, 490-1 and 496. At common law, the term "objective circumstances" was used to describe the circumstances of the crime. The gravity of the offence was assessed by reference to its objective seriousness: R v McNaughton [2006] NSWCCA 242; (2006) 66 NSWLR 566 at [15].
2. The task requires the court to consider where in the range of conduct covered by the offence the conduct of the offender falls: Baumer v R [1988] HCA 67; (1988) 166 CLR 51 at 57. This assessment will generally indicate the appropriate range of sentences available which will reflect the objective seriousness of the offence committed, and set the limits within which a sentence proportional to the criminality of the offender will lie: BW v R [2011] NSWCCA 176 at [70].
3. The sentencing judge should take into account not only the conduct which actually constitutes the crime, but also such of the surrounding circumstances as are directly related to that crime and are properly regarded as circumstances of aggravation or mitigation: R v Wilkinson (No. 5) [2009] NSWSC 432 at [61].
4. The existence of a reasonably foreseeable risk to safety that is likely to result in serious injury or death is a factor relative to the gravity of the offence: Capral Aluminium Limited v WorkCover Authority of New South Wales [2000] NSWIRComm 71; (2000) 49 NSWLR 610 at [82]. The question of foreseeability of the risk is to be determined objectively.
5. The court must identify all the factors that are relevant to the sentence, discuss their significance and then make a value judgment as to what is the appropriate sentence given all the factors of the case: Muldrock v The Queen [2011] HCA 39; (2011) 244 CLR 120. This approach to sentencing, known as the "instinctive synthesis" approach, involves the making of a global judgment without any attempt to state precisely how any given factor has influenced the judgment.
6. The Court of Criminal Appeal has recently examined the sentencing process with regard to work health and safety offences in the matter of Nash v Silver City Drilling (NSW) Pty Limited; Attorney General for NSW v Silver City Drilling (NSW) Pty Limited [2017] NSWCCA 96. His Honour Justice Basten at paragraph 34, under the heading 'Assessment of Risk' said: "The sentencing judge commenced his consideration with the proposition that 'greater culpability attaches to the failure to guard against an event the occurrence of which is probable rather than an event the occurrence of which is extremely unlikely'. However the truth of that proposition depends upon other considerations including: (a) the potential consequences of the risk, which may be mild or catastrophic; (b) the availability of steps to lessen, minimise or remove the risk; and (c) whether such steps are complex and burdensome or only mildly inconvenient. Relative culpability depends on assessment of all those factors."
7. Further at paragraph 42 his Honour continued: "The culpability of the Respondent is not necessarily to be determined by the remoteness of the risk occurring, nor by a step‑by‑step assessment of the various elements. Culpability will turn upon an overall evaluation of various factors, which may pull in different directions. Culpability in this case is reasonably high because, even if the pressure event of the force which occurred might not be expected to occur often, the seriousness of the foreseeable resultant harm is extreme and the steps to be taken to avoid it, were not even assessed, were straightforward and involved only minor inconvenience and little, if any, costs."
8. At paragraph 53 his Honour dealt with the proper approach to considering the objective seriousness of offences under the Act, saying: "It is important to note that the risk to be assessed is not the risk of the consequence, to the extent that a worker is in fact injured, but is the risk arising from the failure to take reasonably practicable steps to avoid the injury occurring. To discount the seriousness of the risk by reference to the unlikelihood of injury resulting is apt to lead to error. The conduct in question is the failure to respond to a risk of injury, conduct which will be more serious, the more serious the potential injuries, whether or not they are likely to materialize. The objective seriousness of the conduct will also be affected by the ease with which mitigating steps could have been taken."
9. My findings about the offender's level of culpability for the Work Charge are based upon the following: 1. Employees of the offender were placed at risk of death or serious injury. The risk of a worker being struck by a train and being killed was obvious, identifiable and foreseeable; 2. It goes without saying that the potential for the risk was known to the offender; 3. The existence of the risk was known to the offender, as the risk was identified in the offender's safety documentation; 4. The likelihood of the risk coming home was quite high, as the train which struck the deceased was travelling on the main up line in a busy area of the offender's rail network; 5. The death of Mr Lagaaia was a manifestation of the risk; 6. Simple remedial steps were available which would have completely avoided the risk. The Signals Team should have been included in the work briefings, and they should have been informed which areas of the track were not protected from passing rail traffic; 7. The offender had a safety management system in place, but there was no explanation why it was not followed.
10. I find that the offender's level of culpability for the Work Charge is in the high end of the mid-range.
11. My findings about the offender's level of culpability for the Preparation Charge are based upon the following: 1. Employees of the offender were placed at risk of death or serious injury. The risk of a worker being struck by a train was obvious, identifiable and foreseeable; 2. The existence of the risk was known to the offender, and it was the reason for having Procedure NWT 300; 3. A simple remedial step was available which would have completely avoided the risk. This was the obtaining and issuing of a TOA, as was belatedly done during the preparation work. No explanation was provided as to why this was not done earlier and thus the workers remained exposed to the risk for about 100 minutes; 4. It is not possible to make a finding about the likelihood of the risk coming home. The points which would have given access to the work area were clipped, and unless those clips were removed, the clipping of the points would have provided some protection to the workers; 5. Fortunately no train entered into the work area and there were no injuries suffered by the offender's workers; 6. The offender had a safety management system in place, but there was no explanation why it was not followed.
12. I find that the offender's level of culpability for the Preparation Charge is in the low end of the mid-range.

Deterrence

1. The penalty imposed in relation to this offence must provide for general deterrence. Rail operators must take the obligations imposed by the Law very seriously. The community is entitled to expect that rail operators will comply with safety requirements. General deterrence is a significant factor when safety obligations are breached: Bulga Underground Operations Pty Limited v Nash [2016] NSWCCA 37; (2016) 93 NSWLR 338 at [180].
2. The penalty must reflect the need for specific deterrence. The offender is still a major rail transport operator. Its operations involve the continuing engagement of thousands of workers, in an environment which is extremely dangerous unless safety is paramount.

Aggravating factors

1. Mr Lagaaia died as a result of the failure of the offender. The injury, emotional harm, loss or damage caused by the Work Charge was substantial: s 21A(2)(g) Crimes (Sentencing Procedure) Act 1999.

Mitigating factors

1. The offender has no previous convictions: s 21A(3)(e) of the Crimes (Sentencing Procedure) Act 1999.
2. The offender is otherwise of good character: s 21A(3)(f) of the Crimes (Sentencing Procedure) Act 1999. The steps which the offender took after the incident demonstrate this.
3. The offender is unlikely to re-offend: s 21A(3)(g) of the Crimes (Sentencing Procedure) Act 1999.
4. The offender has good prospects of rehabilitation: s 21A(3)(h) Crimes (Sentencing Procedure) Act 1999. The offender has taken positive steps to guard against the risk of an incident such as this ever happening again. The offender has continually improved its documentation and its procedures. Specific improvements have been made as a result of this tragedy.
5. The offender has shown remorse for the offence: s 21A(3)(i) Crimes (Sentencing Procedure) Act 1999. The offender has provided evidence that it has accepted responsibility for its actions and has acknowledged that the death of Mr Lagaaia was caused by its actions.
6. The offender entered a plea of guilty: s 21A(3)(k) Crimes (Sentencing Procedure) Act 1999. The court must take into account the fact that the offender has pleaded guilty, when the offender pleaded guilty, and the circumstances in which the offender indicated an intention to plead guilty: s 22(1) Crimes (Sentencing Procedure) Act 1999. It is appropriate to give the offender a 25% discount for an early plea.
7. The offender gave assistance to law enforcement authorities: s 21A(3)(m) Crimes (Sentencing Procedure) Act 1999. The offender co-operated at all times with the prosecutor and other investigating bodies and provided all documents requested in a prompt fashion.

Totality

1. Where two offences of which an offender stands convicted contain common elements, it would be wrong to punish that offender twice for the commission of the elements that are common - Pearce v The Queen [1998] HCA 57; (1998) 194 CLR 610 at [40].
2. Counsel for the prosecutor acknowledged that the Work Charge and the Preparation Charge arise under the same section of the Law and involved the same risk, as well as the element of exposure to death or serious injury. Those matters are common to both offences. However, the places where the offences arose, the times at which the offences were committed, the work being undertaken, the employees who were put at risk, and the steps which should have been taken to eliminate or control the risks, were all different. In reality there is little overlap between the two offences.

Capacity to pay a fine

1. I am required to have regard to s 6 of the Fines Act 1996 before imposing a fine. Where an offender seeks to have a fine reduced on the basis of a limited capacity to pay, it bears the evidentiary onus of convincing the court that it should exercise its discretion to limit the amount of the fine. The offender's capacity to pay is relevant but not decisive: Mahdi Jahandideh v The Queen [2014] NSWCCA 178 at [16]. A substantial fine may still be warranted as a result of the seriousness of the offence and the need for general deterrence.
2. In Unity Pty Limited v SafeWork NSW [2018] NSWCCA 266 the Court of Criminal Appeal said: "First, and more generally, questions of specific deterrence should take into account the size and scope of the operations of the defendant; a fine which may be crippling to a small business may have virtually no impact on the financial operations of a large corporation. The maximum penalty for the offence is undoubtedly set having regard to such a factor. Secondly, the Court is required to have regard to 'the means' of the defendant, pursuant to s 6 of the Fines Act 1996."
3. There was no submission about capacity to pay, so this issue does not arise.

Costs

1. The parties have agreed to an order that the offender is to pay the prosecutor's costs.

Penalty

1. The court extends its sympathies to Mr Lagaaia's wife, children, grandchildren and wider family. By its plea of guilty, Sydney Trains has acknowledged that it is criminally responsible for the death of Mr Lagaaia. It would be understandable if the family thinks that the fines imposed are inadequate. No-one should have to suffer such grief and loss. It is to be hoped that the significant improvements in rail safety made by Sydney Trains as a result of this incident will mean that no family is ever put through that trauma again.
2. My orders in relation to the Work Charge (2018/183611) are: 1. The offender is convicted. 2. The appropriate fine is $500,000 but that will be reduced by 25% to reflect the plea of guilty. 3. Order the offender to pay a fine of $375,000. 4. Order pursuant to Section 260A of the Rail Safety National Law (NSW) that 50% of the fine is to be paid to the prosecutor. 5. Order the offender to pay the prosecutor's costs.
3. My orders in relation to the Preparation Charge (2018/183633) are: 1. The offender is convicted. 2. The appropriate fine is $200,000 but that will be reduced by 25% to reflect the plea of guilty. 3. Order the offender to pay a fine of $150,000. 4. Order pursuant to Section 260A of the Rail Safety National Law (NSW) that 50% of the fine is to be paid to the prosecutor. 5. Order the offender to pay the prosecutor's costs.

DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment or decision. The onus remains on any person using material in the judgment or decision to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court or Tribunal in which it was generated. Decision last updated: 02 September 2019