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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: RO-2019-009-SI-004Management of late-notice roster changes
Number: RO-2019-009-SI-004
Description: RO-2019-009-SI-004:Queensland Rail’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes.
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 29 Mar 2022
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: RO-2019-009-SI-001Placement of signal aspect indicators at station platforms
Number: RO-2019-009-SI-001
Description: RO-2019-009-SI-001:Queensland Rail's process for the installation of signal aspect indicators (SAIs) did not provide sufficient detail to ensure consistent and conspicuous placement of SAIs at station platforms. This problem, combined with an SAI’s non-salient indication when the platform departure signal displayed a stop indication, increased the risk that an SAI ...
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 29 Mar 2022
Status: Closed – Partially addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2019-009-SI-003Risk management associated with changing allright signal procedures for the NGR
Number: RO-2019-009-SI-003
Description: RO-2019-009-SI-003:Limitations in Queensland Rail’s application of risk management and change management processes relevant to the introduction of the new generation rollingstock (NGR) increased the risk of a start against signal SPAD (signals passed at danger). Specifically, multiple processes did not effectively consider the risk of station staff at suburban platforms ...
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 29 Mar 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2018-018-SI-05 Fatigue management of train drivers
Number: RO-2018-018-SI-05
Description: RO-2018-018-SI-05 :BHP's fatigue management processes required its train drivers to be rostered on 7 12-hour shifts, followed by a 24-hour break and then 7 12-hour shifts, with the roster pattern commencing at a wide variety of times of day. Such roster patterns were conducive to result in cumulative sleep restriction and ...
Issue owner: BHP Billiton Iron Ore - Train Operator
Operation affected: Rail: Freight
Date, status, type
Date: 17 Mar 2022
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: RO-2018-018-SI-04Recovery controls – ATP/ECPB interaction
Number: RO-2018-018-SI-04
Description: RO-2018-018-SI-04:The automatic train protection (ATP) and electronically controlled pneumatic braking (ECPB) systems on BHP’s trains could not interface to dump brake pipe pressure if an ECPB emergency or penalty brake application became ineffective in arresting an uncommanded train movement.
Issue owner: BHP Billiton Iron Ore - Train Operator
Operation affected: Rail: Freight
Date, status, type
Date: 17 Mar 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2018-018-SI-03Operating instructions – brake pipe emergencies and penalties
Number: RO-2018-018-SI-03
Description: RO-2018-018-SI-03:Although operating instructions OI 17-11 (5 April 2017) and then OI 18-72 (3 November 2018) contained a safety-critical action (to apply the automatic brake handle to the pneumatic emergency position), BHP did not clearly communicate the importance and reasons for the safety-critical action to drivers, reducing the potential for the ...
Issue owner: BHP Billiton Iron Ore - Train Operator
Operation affected: Rail: Freight
Date, status, type
Date: 17 Mar 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2018-018-SI-02 Task design – brake pipe emergencies and penalties
Number: RO-2018-018-SI-02
Description: RO-2018-018-SI-02 :The task of responding to brake pipe emergencies or penalties relied extensively on a driver’s memory, with limited processes in place to facilitate or cross-check a driver’s performance to ensure all safety-critical actions were completed.
Issue owner: BHP Billiton Iron Ore - Train Operator
Operation affected: Rail: Freight
Date, status, type
Date: 17 Mar 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2018-018-SI-01Risk assessment for a rail-mounted equipment interaction incident
Number: RO-2018-018-SI-01
Description: RO-2018-018-SI-01:Although BHP’s risk assessment for a rail-mounted equipment interaction incident identified numerous causes and critical controls for such an incident, it was broad in scope and had limited focus on the causes and critical controls for a train runaway event. In addition, the risk assessment did not include the procedure ...
Issue owner: BHP Billiton Iron Ore - Train Operator
Operation affected: Rail: Freight
Date, status, type
Date: 17 Mar 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2019-018-SI-03Inconsistencies with application of fatigue management system
Number: RO-2019-018-SI-03
Description: RO-2019-018-SI-03:There were inconsistences with Sydney Trains’ application of their fatigue management system, in particular the the use of a bio-mathematical model to predict individual fatigue risk. (Safety issue)
Issue owner: Sydney Trains
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Dec 2021
Status: Closed – Adequately addressed
Issue, description, who it affects
Issue: RO-2019-018-SI-02Signaller supervision
Number: RO-2019-018-SI-02
Description: RO-2019-018-SI-02:Sydney Trains did not provide supervision at Granville signal box to ensure there was adequate coverage on both signalling panels. (Safety issue)
Issue owner: Sydney Trains
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Dec 2021
Status: Closed – Adequately addressed
Issue, description, who it affects
Issue: RO-2019-018-SI-01The ASB rule and procedure for using an alternative route
Number: RO-2019-018-SI-01
Description: RO-2019-018-SI-01:The ASB rule NWT 308 and procedure NPR 703 did not provide sufficient description for the task of using protecting signals for an alternative route. (Safety issue)
Issue owner: Sydney Trains
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Dec 2021
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2020-019-SI-01Absence of authority-overrun protection
Number: RO-2020-019-SI-01
Description: RO-2020-019-SI-01:The absence of authority-overrun protection (such as TPWS) at signal SST535 increased the potential consequences of a SPAD.
Issue owner: V/Line Corporation
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 07 Dec 2021
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: RO-2020-008-SI-03Unaware of forced lead function
Number: RO-2020-008-SI-03
Description: RO-2020-008-SI-03:The train crew had not been trained to use forced lead function which would likely have allowed the train crew to regain control of the locomotives
Issue owner: Aurizon
Operation affected: Rail: Rolling stock
Date, status, type
Date: 26 Oct 2021
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2020-008-SI-02Change of ends process is unclear
Number: RO-2020-008-SI-02
Description: RO-2020-008-SI-02:Aurizon did not ensure train crews had a consistent understanding of how to safely change ends on banking locomotives
Issue owner: Aurizon
Operation affected: Rail: Rolling stock
Date, status, type
Date: 26 Oct 2021
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2020-008-SI-01The park brakes were ineffective
Number: RO-2020-008-SI-01
Description: RO-2020-008-SI-01:The park brakes were ineffective in holding the locomotives on the grade in Ardglen Yard
Issue owner: Aurizon
Operation affected: Rail: Rolling stock
Date, status, type
Date: 26 Oct 2021
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2020-006-SI-01 Unapproved practice during TWA
Number: RO-2020-006-SI-01
Description: RO-2020-006-SI-01 :There was an unapproved practice occurring during Track Work Authority of asking the Outer Handsignaller to remove Railway Track Signals from the track as a train was closely approaching in order to let it run free, which placed the Outer Handsignaller at risk of being struck by the train.
Issue owner: Sydney Trains
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 May 2021
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: RO-2018-002-SI-05Use of event recorders to monitor driver performance
Number: RO-2018-002-SI-05
Description: RO-2018-002-SI-05:Prior to the signal passed at danger (SPAD) occurrence in January 2018, Queensland Rail did not routinely and systematically analyse recorded data to determine driver compliance with key operational rules that had been designed to minimise the risk of SPADs.
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 15 Apr 2021
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2018-002-SI-04 Implementation of risk triggered commentary driving (RTCD)
Number: RO-2018-002-SI-04
Description: RO-2018-002-SI-04 :After mandating the use of risk triggered commentary driving (in 2011) to mitigate the risk of signals passed at danger, Queensland Rail Citytrain did not provide the necessary support to its trainers, assessors and drivers to effectively maximise the potential benefits of the technique and minimise the potential limitations or ...
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 15 Apr 2021
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2018-002-SI-03Design of the automatic warning system (AWS)
Number: RO-2018-002-SI-03
Description: RO-2018-002-SI-03:The automatic warning system (AWS) provided the same audible alarm and visual indication to a driver on the approach to all restricted signals (that is, double yellow, yellow, flashing yellow and red aspects). The potential for habituation, and the absence of a higher priority alert when approaching a signal displaying ...
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 15 Apr 2021
Status: Closed – Partially addressed
Type: Proactive action
Issue, description, who it affects
Issue: RO-2018-002-SI-02Oversight of the train driver maintenance of competency process
Number: RO-2018-002-SI-02
Description: RO-2018-002-SI-02:Queensland Rail’s management oversight of the Citytrain driver maintenance of competency (MOC) process did not include planned assurance activities or regular and effective auditing of how the MOC assessments were being conducted, even after there were multiple indications that the process was not being conducted as designed.
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 07 Apr 2021
Status: Closed – Adequately addressed
Type: Proactive action
First page Page 1 of 29 Last page Total records: 575