Preliminary findings From the evidence available, the following preliminary findings are made with respect to the fatality at Guildford, Western Australia on 10 February 2015. findings should not be read as apportioning blame or liability to any particular organisation or individual. A Safety issues, or system problems, are highlighted in bold to emphasise importance. safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time. Contributing factors Worksite protection had not been adequately implemented to ensure workers were protected against inadvertently stepping into the path of a train while undertaking maintenance work. It was common practice for maintenance personnel to adopt a process that was inherently less safe than an alternative when maintaining automatic pedestrian crossing equipment. The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment. [Safety
Preliminary findings From the evidence available, the following preliminary findings are made with respect to the fatality at Guildford, Western Australia on 10 February 2015. findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasise importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time. Contributing factors Worksite protection had not been adequately implemented to ensure workers were protected against inadvertently stepping into the path of a train while undertaking maintenance work. It was common practice for maintenance personnel to adopt a process that was inherently less safe than an alternative when maintaining automatic pedestrian crossing equipment. The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment. [Safety
ro2015002_prelim.docx