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HP-012       Reviewed 23/07/2021

EM-002-00: Management of Change

(National Regulations – regulation 9, schedule 1 cl 12)

OTHR has implemented a change management procedure to ensure that proposed changes within its rail operation are appropriately documented and potential rail safety risks identified, described and controls implemented to reduce risk, to a level that is So Far as is Reasonably Practicable (SFARP).

Proposed changes that may affect safety at OTHR are undertaken in accordance with OTHR’s Change Management Procedure. Key requirements of this procedure are consultation, communication, risk assessment and review.

Changes that affect safety to OTHR’s operations may arise from a number of sources, including:

  • Change to management/governance structure;
  • Change to the design of infrastructure or rolling stock (including changes to the design of their individual components);
  • Change to infrastructure and rolling stock inspection and maintenance practices;
  • Introducing a new item of rollingstock to service (including an item which has undergone extensive restoration from static display or a state previously unfit for purpose); and
  • Changes to operating rules.

OTHR is required to submit notifications of some types of change to ONRSR. This also includes submission of an application to vary accreditation where the scope and nature of the change may result in a change to accreditation.

The change management procedure is authorised by the Management Committee which also regularly reviews progress when implementing changes.

Summary of the OTHR Change Management Process:


EM-002-00 Management of Change

EM-002-01 OTHR Management of Change Procedure-01072021

EM-002-F1 OTHR-Engineering Change Advice-01072021

OTHR Associated Documents:


Last updated: July 23, 2021 at 8:50 am

HP-011      Reviewed 16/07/2021

AR-003-00: Corrective Actions

(National Regulations – schedule 1 cl 11)

‘Corrective Action’ is the term given to any action that is identified as a weakness or deficiency in a Safety Management System.

Corrective actions can be identified from a number of sources, including but not limited to:

  • Audits – internal and external;
  • Document /SMS review processes;
  • Incident Reports;
  • Investigation findings;
  • Risk Assessments;
  • Routine maintenance inspections of infrastructure and individual items of rolling stock;
  • Suggestions from people who work with the SMS or specific procedures; and
  • Anything that has occurred outside the organisation but could have an impact on the operations.

These are all items that require attention to improve and maintain safety and are tracked by OTHR to ensure they are resolved.

OTHR maintains a register of corrective actions to monitor status and to identify responsibility for closing out the action.


AR-003-00 Corrective Actions

AR-003-01 Corrective Actions Procedure 01072021

AR-003-F1 Non-Conformance-Report-30th-May-2020

AR-003-F2 External-Audit-Report-30th-May-2020

AR-003-F3 OTHR-Corrective Action Register-01072021

F-010 Injury Reports

F-021 Daily Sign-on Sheet (Reverse Side)

OTHR Associated Documents:

[documents modules=”corrective-action”]

Last updated: July 16, 2021 at 7:37 am

HP-010      Reviewed 16/07/2021

AR-002-00: Safety Audit Arrangements

(National Regulations – schedule 1 cl 10)

The OTHR Management Committee is responsible for establishing and managing the audit program.

There are three levels of audits that may be undertaken:

  • Internal compliance audits: performed by OTHR supervisory personnel.
  • Internal Operational Audits: performed by OTHR managers on an as required basis
  • External compliance audits: performed: by Regulatory Authorities.

The OTHR SMS audit is programmed over a three year period.  The Audit Schedule makes provision for all SMS Elements to be audited at least once in each three-year period.

The OTHR Management Committee will prioritise the internal audit program considering:

  • Previous audit findings and recommendations;
  • Recent rail safety performance; and
  • Risk status of activities to be audited,

The Management Committee will monitor the audit program to ensure audits are completed as scheduled.


AR-002-00 Safety Audit Arrangements 01072021

AR-002-01 Safety Audit Procedure-01072021

AR-002-F2 Internal-Audit-Form-01072021

AR-002-F3 Audit-Checklist-01072021

AR-002-F4 External-Audit-Report-01072021

AR-002-F5 Nonconformance Report 01072021

OTHR Associated Documents


Last updated: July 16, 2021 at 7:09 am

HP-009      Reviewed 15/07/2021

MR-001-00: Safety Performance Measures

(National Regulations –schedule 1 cl 9)

OTHR uses Safety Performance Measures and Reports to monitor the effectiveness of its SMS. Key Performance Indicators (KPI) are used to monitor safety performance and assess whether safety performance requirements are being met.

Measurable Safety performance goals are set in the Annual Safety Report to ONRSR each year and performance is measured against these goals .

Key Performance Indicators (KPI) are used to measure safety performance and assess whether safety performance objectives are being met.

Safety Performance information is communicated within the organisation via toolbox meetings, newsletters, the OTHR website, monthly general meetings and committee meetings. The information is also included in each annual safety performance report.


MR-001-00 Safety Performance Measures 01072021

MR-001-01 Safety Performance Reporting Procedure 01072021

MR-001-02 OTHR Safety Performance Report Template 01072021


OTHR Associated Documents:



Last updated: July 15, 2021 at 20:45 pm

HP-008        Reviewed 15/07/2021

AR-001-00: Review of Safety Management Systems

(National Regulations – regulation 17, schedule 1 cl 8)

OTHR has developed and implemented a procedure to review its safety management system on a regular basis to ensure that it still complies with the law and is working effectively. The regulations state that the review should be at least once a year.

The aim of the review is to consider whether any changes are required to:

  • Assess the effectiveness of the SMS, and identify areas of weakness with a view to rectify these;
  • Assess the effectiveness of any changes since the last review;
  • Review any notifiable occurrences and procedural breaches since the last review;
  • Consider the results from any audits (internal or external);
  • Consider the findings of any incident investigations; and
  • Review any issues identified from prohibition or improvement notices.

The review is required to be summarised and reported in the safety performance report submitted to ONRSR.

Summary of the Review Process:

The following things are done to ensure an effective review and revision:

  • The System’s Manager is responsible for coordinating and implementing the review with the assistance of the committee as required.
  • Undertake consultation amongst our rail safety workers, OTHR members, relevant stakeholders and industry professionals outside of the organisation.  This includes approaching individual Rail Safety Workers at a Tool Box meeting held for this purpose.
  • The review is conducted via a special committee meeting held a couple of months prior to due date of the Annual Safety Performance Report.
  • Minutes of this meeting are kept and include full details of the matters which were considered including copies of supporting documentation.
  • Ensuring a plan is established to implement recommended changes, and any actions are included on the committee ‘outstanding actions list’ to ensure they occur.
  • Communicate the results of the review to rail safety workers via general meetings, toolbox meetings and updates on our website, and members at the AGM
  • The results of the review are summarised and included in the annual Safety Performance Report which is submitted to the Rail Safety Regulator.


AR-001-00 Review of Safety Management Systems 01072021

AR-001-01 Safety Management System Review Procedure 01072021

OTHR Associated Documents:


SMS Review Summary Page

Last updated: July 15, 2021 at 19:51 pm