The twist defect was not detected by TasRail’s inspection/monitoring systems, increasing the risk of derailment.
07 August 2013
To improve the detection of track twist defects, TasRail have taken the following action:
Increased twist trolley inspection regime from 10 weekly to monthly for areas identified as high risk for this section of track. This coincides with the Track Geometry Car which runs 3 monthly thus when this occurs the higher level Track Geometry Car inspection replaces the twist trolly inspection.
Provide refresher training for Track Inspectors utilising external subject matter experts in fault identification and management.
Purchased and issued new track measurement equipment to ensure accuracy and consistency of measurements.
Conduct a review of the process for maintenance inspection management to ensure inspections performed to schedule.
The ATSB is satisfied that the action taken by TasRail should address this safety issue.