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.