Rail safety issues and actions

Assessment and recording of rail safety risks

Issue number: RO-2013-005-SI-03
Who it affects: All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Issue owner: Queensland Rail Limited
Transport function: Rail: Other
Background: Investigation Report RO-2013-005
Issue release date: 20 December 2013
Current issue status: Safety action pending

Safety issue description

Poor wheel/rail adhesion was not recognised as a risk in any of Queensland Rail’s risk registers and therefore this risk to the safety of rail operations was not being actively managed.

Response to safety issue by Queensland Rail

Queensland Rail has implemented a Discipline Head Framework. The Discipline Head framework includes separate risk registers for each of nine specific disciplines. The development of these registers takes into account risks, causes and controls identified in current Queensland Rail risk registers. The controls identified in these registers form the Queensland Rail Safety and Environment Management System.

Each discipline head is responsible for identifying discipline specific risks and controls. To ensure a cohesive approach to risk management, risk registers are shared between discipline heads to ensure that no gaps exist in the identification, assessment and control of safety risks. This process ensures that cross-discipline risks are identified, assessed and controlled.

ATSB comment in response:

The ATSB notes that Queensland Rail has implemented a system of discipline specific risk registers with processes to ensure cross-discipline risks are identified, assessed and controlled. However, no evidence was provided that demonstrated poor wheel/rail adhesion had been recognised as a risk under the new risk management framework.


Action number: RO-2013-005-SR-014
Action organisation: Queensland Rail
Date: 20 December 2013
Action status: Monitor

The Australian Transport Safety Bureau recommends that Queensland Rail undertake further work to ensure poor wheel/rail adhesion is recognised, assessed and controlled under the new risk management framework.

Last update 25 February 2015