Rail safety issues and actions

Change management process implementation for safety critical changes

Issue number: RO-2016-006-SI-02
Who it affects: Rolling Stock Operators
Issue owner: Sydney Tramway Museum
Operation affected: Rail: Operations control
Background: Investigation Report RO-2016-006
Date: 17 May 2019

Safety issue description

STM did not follow its change management process for adopting the new hardwood chock type. Subsequently, the hardwood chock could not be applied reliably under the ‘J’ class wheel and could not restrict its movement.

Proactive Action

Action organisation: Sydney Tramway Museum
Action number: RO-2016-006-NSA-015
Date: 17 May 2019
Action status: Closed

Since the incident, STM has communicated to all staff that any proposed changes are required to be communicated to the Rail Safety Management Team (RSMT). The changes will subsequently be implemented in accordance with STM’s change management procedure.

ATSB response:

The Australian Transport Safety Bureau notes the response provided and is satisfied that the action taken by STM addresses the safety issue.

Current issue status: Adequately addressed
Last update 17 May 2019