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Application of safety actions from internal investigations

Issue number: RO-2013-005-SI-05
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
Operation affected: Rail: Other
Background: Investigation Report RO-2013-005
Date: 20 December 2013

Safety issue description

Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in precipitating appropriate safety action to the findings and recommendations of their investigations into the Beerwah SPADs in 2009 which identified wheel/rail adhesion issues.

Response to safety issue by Queensland Rail

Qld Rail is implementing a newly developed Governance Risk and Compliance (GRC) project. The GRC project is designed to improve access and the quality of our governance, risk and compliance systems across all functional and corporate functions. The GRC will provide clear accountability of required actions including timeframes for completion. A number of existing systems will be decommissioned and consolidated under the GRC project.

The GRC system houses the outcomes and remedial actions stemming from rail safety investigations which will be monitored and tracked through to completion to ensure all relevant actions are undertaken, within the prescribed timeframes. The GRC system provides a systemic risk management database with greater visibility across the organisation to ensure adequate linkages of identified corporate risks and controls to mitigate those risks.

ATSB comment in response:

The ATSB notes that the new Governance Risk and Compliance system is yet to be fully implemented so that findings of investigations which identify safety issues can be appropriately actioned and monitored.

Recommendation

Action organisation: Queensland Rail
Action number: RO-2013-005-SR-016
Date: 20 December 2013
Action status: Monitor

The Australian Transport Safety Bureau recommends that Queensland Rail undertake further work to address this safety issue.

   
Current issue status: Safety action pending
 
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Last update 25 February 2015