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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: RO-2017-013-SI-02Axle fatigue susceptibility
Number: RO-2017-013-SI-02
Description: RO-2017-013-SI-02:The GATX 840P1 axle was susceptible to fatigue cracking due to relatively minor damage that was not reliably detected prior to failure.
Who it affects: All users of 840P1 axles
Issue owner: Incitec Pivot Limited
Operation affected: Rail: Rolling stock
Date, status, type
Date: 12 Jun 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2017-013-SI-01Magnetic particle inspection
Number: RO-2017-013-SI-01
Description: RO-2017-013-SI-01:Anomalies in the magnetic particle inspection procedures likely led to the crack not being detected.
Who it affects: All workers conducting magnetic particle inspection
Issue owner: Aurizon
Operation affected: Rail: Rolling stock
Date, status, type
Date: 12 Jun 2019
Status: Partially addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2016-006-SI-04Use of all available and reasonably practicable risk controls when parking trams
Number: RO-2016-006-SI-04
Description: RO-2016-006-SI-04:STM did not require the application of all available and reasonably practicable risk controls when parking trams with respect to their location and handbrake application.
Who it affects: Rolling Stock Operators
Issue owner: Sydney Tramway Museum
Operation affected: Rail: Operations control
Date, status, type
Date: 17 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-006-SI-03Attending parked trams
Number: RO-2016-006-SI-03
Description: RO-2016-006-SI-03:STM did not comply with its risk control in ensuring that trams were attended when parked.
Who it affects: Sydney Tramway Museum
Issue owner: Sydney Tramway Museum
Operation affected: Rail: Operations control
Date, status, type
Date: 17 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-006-SI-02 Change management process implementation for safety critical changes
Number: RO-2016-006-SI-02
Description: RO-2016-006-SI-02 :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.
Who it affects: Rolling Stock Operators
Issue owner: Sydney Tramway Museum
Operation affected: Rail: Operations control
Date, status, type
Date: 17 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-001-SI-03Maintenance response to recurring track defects in areas with a degraded formation
Number: RO-2016-001-SI-03
Description: RO-2016-001-SI-03:A more stringent maintenance response than that for an isolated track geometry defect was not considered or implemented in accordance with ARTC’s COP. A more stringent maintenance response should have been implemented given the degraded formation and the track’s rapid deterioration between 12-14 January 2016, two days prior to the ...
Who it affects: Rail Infrastructure Managers (RIMs)
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Infrastructure
Date, status, type
Date: 25 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-001-SI-01Shear key installation
Number: RO-2016-001-SI-01
Description: RO-2016-001-SI-01:The shear key was not constructed in accordance with the geotechnical engineer’s specification with respect to the following: a) It did not include a cross-drain. b) Its width was less than the specified width.
Who it affects: Rail Infrastructure Managers (RIMs)
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Infrastructure
Date, status, type
Date: 25 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-001-SI-02Surface drainage in areas with degraded formations
Number: RO-2016-001-SI-02
Description: RO-2016-001-SI-02:The infrastructure manager did not ensure that there was adequate surface drainage. Vegetation blocking the drains and the lack of an adequate gradient as well as the location being at a sag point likely contributed to this. 
Who it affects: Rail Infrastructure Managers (RIMs)
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Infrastructure
Date, status, type
Date: 25 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2017-016-SI-01Track defect management
Number: RO-2017-016-SI-01
Description: RO-2017-016-SI-01:ARTC allowed identified track twist defects to remain in track contrary to network track geometry requirements.
Who it affects: Track Managers
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Freight
Date, status, type
Date: 06 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2018-002-SI-01Train driver maintenance of competency assurance
Number: RO-2018-002-SI-01
Description: RO-2018-002-SI-01:Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements.
Who it affects: Queensland Rail Citytrain rail traffic drivers
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Feb 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2017-001-SI-01Loading of train
Number: RO-2017-001-SI-01
Description: RO-2017-001-SI-01:The train was loaded by approximately 10 per cent more than that recorded on the consist, it is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train.
Who it affects: All owners and operators of freight wagons
Issue owner: Qube Logistics
Operation affected: Rail: Freight
Date, status, type
Date: 05 Dec 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-023-SI-01 Rail condition
Number: RO-2015-023-SI-01
Description: RO-2015-023-SI-01 :The general condition of the rail on the west track, in the vicinity of the rail fracture, contributed to relatively frequent failures in that area.
Who it affects: Users of the affected rail track
Issue owner: BHP Billiton
Operation affected: Rail: Freight
Date, status, type
Date: 12 Oct 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-004-SI-01Preventative maintenance systems
Number: RO-2016-004-SI-01
Description: RO-2016-004-SI-01:The presence of the earlier design of yoke on wagon NGKF 35898X was not detected during preventative maintenance activities.
Who it affects: Pacific National
Issue owner: Pacific National
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Jun 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-07Train radio functionality
Number: RO-2016-002-SI-07
Description: RO-2016-002-SI-07:The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to override an initial lower-priority call.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-06Standard for derailment risk on small-radius curves
Number: RO-2016-002-SI-06
Description: RO-2016-002-SI-06:There was no network standard that directly dealt with increased derailment risk on small-radius curves.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-05Management of wide gauge defect
Number: RO-2016-002-SI-05
Description: RO-2016-002-SI-05:Track geometry through the Rushall curve was not managed in accordance with Metro Trains Melbourne (MTM) network standards. A wide-gauge ‘A’ fault was not rectified in the field despite being closed-out on the asset management system.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-02Standard for angular discontinuity at mechanical joints
Number: RO-2016-002-SI-02
Description: RO-2016-002-SI-02:The network’s track geometry standard did not include any specific requirement to limit a localised lateral angular discontinuity in rail line at a mechanical joint.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-04Track geometry standards
Number: RO-2016-002-SI-04
Description: RO-2016-002-SI-04:The network’s track geometry standards were probably unsuitable for small-radius Broad-Gauge curves. A combination of track geometry irregularities had increased the probability of flange-climb at several locations on the small-radius Rushall curve.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-03Location of rail lubricators
Number: RO-2016-002-SI-03
Description: RO-2016-002-SI-03:The positioning of the rail lubricators at this and several other locations on the network was not consistent with Metro Trains Melbourne (MTM) guidelines and probably reduced their effectiveness.
Who it affects: Rail: Passenger – metropolitan and regional
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-01Rail lubricator maintenance
Number: RO-2016-002-SI-01
Description: RO-2016-002-SI-01:The maintenance of rail lubricators had become less effective in the months leading up to the derailment. This work was being transferred from contractors to internal Metro Trains Melbourne (MTM) staff and the transition was not adequately managed.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Adequately addressed
Type: Proactive Action
First page Page 1 of 26 Last page Total records: 508