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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: RO-2015-029-SI-04Track maintenance personnel training and development
Number: RO-2015-029-SI-04
Description: RO-2015-029-SI-04:There was an identified gap in the knowledge of track maintenance personnel that was probably the result of deficiencies in training and development. In addition, network standards for the assessment of track lateral stability, including creep management, provided limited information and tools for maintenance personnel.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 12 Jul 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-029-SI-03Other track inspections
Number: RO-2015-029-SI-03
Description: RO-2015-029-SI-03:There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 12 Jul 2017
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-029-SI-02Correcting rail creep for fixed points
Number: RO-2015-029-SI-02
Description: RO-2015-029-SI-02:Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 12 Jul 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-029-SI-01Rail creep
Number: RO-2015-029-SI-01
Description: RO-2015-029-SI-01:Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 12 Jul 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-007-SI-01 Rail fractures
Number: RO-2016-007-SI-01
Description: RO-2016-007-SI-01 :The inspection regime to identify rail fractures was ineffective for the condition of this track.
Who it affects: All operators of rail freight
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Freight
Date, status, type
Date: 30 May 2017
Status:
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2015-022-SI-04 Correcting rail creep for fixed points
Number: RO-2015-022-SI-04
Description: RO-2015-022-SI-04 :Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-03 Timeframe for addressing identified rail creep
Number: RO-2015-022-SI-03
Description: RO-2015-022-SI-03 :The procedures for measuring, assessing, and remediating rail creep in spring did not ensure creep defects were addressed in a timely manner and prior to the onset of hot weather. A creep defect identified by the spring measurements was not corrected before the derailment.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-02 Other track inspections
Number: RO-2015-022-SI-02
Description: RO-2015-022-SI-02 :There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-01 Rail creep
Number: RO-2015-022-SI-01
Description: RO-2015-022-SI-01 :Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-009-SI-02 Network rule governing Distant signals
Number: RO-2015-009-SI-02
Description: RO-2015-009-SI-02 :The rule describing the required driver response to a Distant signal at Caution in a two-position signalling system did not fully reflect the signalling system design principles. 
Who it affects: Drivers operating on rail networks using this rule
Issue owner: V/Line
Operation affected: Rail: Operations control
Date, status, type
Date: 12 Dec 2016
Status: Not addressed
Type: Recommendation
  Proactive Action
Issue, description, who it affects
Issue: RO-2015-009-SI-01 Driver training
Number: RO-2015-009-SI-01
Description: RO-2015-009-SI-01 :The training and assessment of the driver did not ensure that he had an adequate understanding of the two-position signalling through Marshall. 
Who it affects: Drivers operating on the V/Line network
Issue owner: V/Line
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 12 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-028-SI-02 Operational rules and procedures
Number: RO-2015-028-SI-02
Description: RO-2015-028-SI-02 :The Queensland Rail network rules, procedures and safety manual provided insufficient guidance to identify the magnitude of the potential hazard from a weather event, or define the response when encountering water that had previously overtopped the track and receded or was pooled against the track formation or ballast.
Who it affects: All rail safety workers conducting work on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-028-SI-01 Hazard identification and assessment by rail traffic crew
Number: RO-2015-028-SI-01
Description: RO-2015-028-SI-01 :The Queensland Rail General Operational Safety Manual (MD-10-107) contained insufficient guidance for rail traffic crews to ensure the timely identification and management of a potential hazard (resulting from a weather event) that might affect the safe progress of the train.
Who it affects: All rail transport operators working rolling stock on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-016-SI-02Passenger Train Marker Light Standards
Number: RO-2014-016-SI-02
Description: RO-2014-016-SI-02:The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.
Who it affects: Rail Operators on Melbourne Metropolitan Rail Network
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Other
Date, status, type
Date: 06 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-016-SI-01Permissive Signalling System
Number: RO-2014-016-SI-01
Description: RO-2014-016-SI-01:The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.
Who it affects: Rail Operators on Melbourne Metropolitan Rail Network
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Other
Date, status, type
Date: 06 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2015-015 SI-02Low rim thickness
Number: RO-2015-015 SI-02
Description: RO-2015-015 SI-02:Despite a number of incidents, Pacific National did not take adequate action, before the derailment, to reduce the risk of wheel defects, especially in light of previously identified contributors such as low rim thickness. 
Who it affects: All owners and operators of heavy haul freight wagons.
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 30 Jun 2016
Status:
Issue, description, who it affects
Issue: RO-2015-015 SI-01Wheel inspection processes
Number: RO-2015-015 SI-01
Description: RO-2015-015 SI-01:The wheel inspection processes and systems were not effective in detecting surface damage or cracks on the R4 wheel on wagon NHIH97081 prior to the wheel failure.
Who it affects: All owners and operators of heavy haul freight wagons
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 30 Jun 2016
Status:
Issue, description, who it affects
Issue: RO-2014-005-SI-04Train / platform clearances
Number: RO-2014-005-SI-04
Description: RO-2014-005-SI-04:Due to the curvature of the track, a wide gap existed between the platform and train at the Heyington Railway Station. There are several stations on the Melbourne metropolitan rail network where wide gaps exist between platforms and trains due to track curvature. These gaps pose a risk to passengers.
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-005-SI-03Standards for train / platform clearances
Number: RO-2014-005-SI-03
Description: RO-2014-005-SI-03:The existing standards stipulated minimum clearances between trains and platforms but did not consider the effect of the resulting gaps with respect to safe accessibility. 
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-005-SI-02Inadequacy of the doors open warning device
Number: RO-2014-005-SI-02
Description: RO-2014-005-SI-02:The train door open/close indicator on the driver’s control console was inadequate as a warning device once the traction interlock had deactivated. 
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: No longer relevant
Type: Recommendation
Issue, description, who it affects
Issue: RO-2014-005-SI-01The train could be moved with the carriage doors open
Number: RO-2014-005-SI-01
Description: RO-2014-005-SI-01:As designed, the traction interlock automatically deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2015-005-SI-01Fatigue management
Number: RO-2015-005-SI-01
Description: RO-2015-005-SI-01:Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver. 
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 29 Jan 2016
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-026-SI-01 Identification of defect location
Number: RO-2013-026-SI-01
Description: RO-2013-026-SI-01 :When the AK Car was operating in Manual mode, the methods used to identify the location of a defect, and assist track staff to locate the defect could be ineffective in certain scenarios. At the derailment location, there was a consistent offset of about 58 m between the recorded location ...
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-026-SI-02 Track patrols
Number: RO-2013-026-SI-02
Description: RO-2013-026-SI-02 :Track patrol processes were ineffective at detecting and remedying the wide gauge defect at the derailment location. Track patrols were overly reliant on the AK Car geometry recording vehicle to trigger maintenance action on this track geometry defect.  
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-026-SI-03Actions following derailment on 11 September 2013
Number: RO-2013-026-SI-03
Description: RO-2013-026-SI-03:The ARTC response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October.  
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-026-SI-04Rail head wear
Number: RO-2013-026-SI-04
Description: RO-2013-026-SI-04:ARTC processes for managing the condition of the rail were ineffective despite repeated recording of rail head wear by the AK Car, and local knowledge of the worn rail. The rail was worn beyond the rail condemning limits specified within the network code of practice.
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-010-SI-02Local Appendix Unit – North V3
Number: RO-2015-010-SI-02
Description: RO-2015-010-SI-02:The ARTC Local Appendix Unit North – Volume 3 did not reflect current equipment installation arrangements for E Frame at Singleton.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 06 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-010-SI-01Unique indications for E Frame on Network control system screens
Number: RO-2015-010-SI-01
Description: RO-2015-010-SI-01:The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 05 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-007-SI-03Train pathing
Number: RO-2015-007-SI-03
Description: RO-2015-007-SI-03:The practice of pathing a following train onto a line occupied by a preceding train, when an alternate route was available and not obstructed, presented an elevated level of risk.
Who it affects: All rail transport operators throughout Australia
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Dec 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-007-SI-04Pre-warning train driver of occupied track
Number: RO-2015-007-SI-04
Description: RO-2015-007-SI-04:The practice of pathing a following train onto the same line occupied by a preceding train, without pre-warning the driver regarding the train ahead, presented an elevated level of risk.
Who it affects: All rail transport operators throughout Australia
Issue owner: Australian Rail Track Corporation and SCT Logistics
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Dec 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-007-SI-05National Train Communications System (NTCS) – Broadcast communications
Number: RO-2015-007-SI-05
Description: RO-2015-007-SI-05:The design of the NTCS in screening Adelaide metro broadcast communications prevented the driver of 2MP9 from gaining an appreciation of activities close to his area of operation, in particular the position of train 2MP1 along the Mile End main line.
Who it affects: All rail transport operators throughout Australia
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Dec 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-007-SI-01End of train conspicuity
Number: RO-2015-007-SI-01
Description: RO-2015-007-SI-01:Vegetation and a low fence adjacent the Mile End crossing loop partially obscured the view that the crew of train 2MP9 had of the empty flat wagons at the rear of train 2MP1.
Who it affects: All rail transport operators throughout Australi
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Dec 2015
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2015-003-SI-01 Safeworking systems and processes
Number: RO-2015-003-SI-01
Description: RO-2015-003-SI-01 :There were no formal systems in place to manage the accepted practice of Protection Officers leaving a work site to return a Track Warrant and Train Staff, prior to ceasing works, off-tracking and ensuring the line was clear. This practice led to the informal delegation of responsibility for ensuring the ...
Who it affects: V/Line Pty Ltd
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 09 Dec 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-001-SI-001Wheel slip protection indicator light
Number: RO-2014-001-SI-001
Description: RO-2014-001-SI-001:Drivers are desensitised to the wheel slip protection indicator light activations through its regular activation in response to momentary losses of adhesion. This, coupled with the inadequate warning provided by the TMS, may result in delayed reaction in response to activations that need driver intervention.
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Rolling stock
Date, status, type
Date: 03 Dec 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-001-SI-002 Reporting and Verbal Communications
Number: RO-2014-001-SI-002
Description: RO-2014-001-SI-002 :Reporting and communications were not carried out in accordance with Sydney Trains rules and procedures, so that key employees in the Rail Management Centre received delayed and/or partial information and allowed the train to continue in service.
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Operations control
Date, status, type
Date: 03 Dec 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-001-NSA-025Rail Resource Management
Number: RO-2014-001-NSA-025
Description: RO-2014-001-NSA-025:Key staff had not been trained in Rail Resource Management. 
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Operations control
Date, status, type
Date: 03 Dec 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-001-SI-004Incident Rail Commander Role
Number: RO-2014-001-SI-004
Description: RO-2014-001-SI-004:The lack of an appointed Officer in Charge of the incident site prior to the arrival of an Incident Rail Commander led to a fragmented response with no single employee having a recognised leadership role on site. 
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Operations control
Date, status, type
Date: 03 Dec 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-014-SI-01Detection of rail defects
Number: RO-2014-014-SI-01
Description: RO-2014-014-SI-01:The scheduled ultrasonic tests conducted in November 2013 on the 80 lb/yd rail between Northgate and Alice Springs had been ineffective in detecting and quantifying the significant defects present at 1036.541 km and 975.244 km locations.
Who it affects: All rail track managers
Issue owner: Genesee & Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 28 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-014-SI-02Special locations
Number: RO-2014-014-SI-02
Description: RO-2014-014-SI-02:Contrary to the requirements of procedure IN-PRC-020, GWA had not established a list of specific locations known to have an increased likelihood of failure, such that particular attention may be applied in those locations during inspections.
Who it affects: All rail track managers
Issue owner: Genesee & Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 28 Oct 2015
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-020-SI-01The insulated rail joints were incorrectly placed
Number: RO-2013-020-SI-01
Description: RO-2013-020-SI-01:The placement of the insulated rail joints adjacent to signal DYN150 was not in accordance with the ARTC engineering procedure ESC-07-01.
Who it affects: Network Control
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-020-SI-02Communication protocols at the Melbourne Freight Terminal
Number: RO-2013-020-SI-02
Description: RO-2013-020-SI-02:The practice of using a third party (the shunt planner) to facilitate communication between Network Control Officers and train drivers at the Melbourne Freight Terminal prevented an effective response to the emergency.
Who it affects: Network Control
Issue owner: Pacific National
Operation affected: Rail: Operations control
Date, status, type
Date: 16 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-018-SI-01 Maintenance, defect monitoring and reporting as per CoP
Number: RO-2014-018-SI-01
Description: RO-2014-018-SI-01 :Track defect monitoring and reporting was not being conducted as specified in the Westrail Narrow Gauge Mainline Code of Practice, limiting the awareness of the deteriorating track condition and the need for reassessment of track operating limits.
Who it affects: Rail infrastructure maintainers
Issue owner: Transfield Services
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-018-SI-02 Oversight of Infrastructure Maintenance
Number: RO-2014-018-SI-02
Description: RO-2014-018-SI-02 :The rail transport operator (GWA) had not maintained sufficient oversight of the activities of the rail infrastructure manager (Transfield Services), allowing the track to deteriorate to a level where trains could not be reliably run in a safe manner.
Who it affects: Rail network managers and owners
Issue owner: Genesee & Wyoming Australia
Operation affected: Rail: Infrastructure
Date, status, type
Date: 09 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-024-SI-01Management of lineside foliage
Number: RO-2014-024-SI-01
Description: RO-2014-024-SI-01:V/Line’s process for the inspection of level crossing sighting did not provide explicit instructions for the identification and removal of problem vegetation.
Who it affects: All road users and operators of trains on trackage owner or managed by V/Line.
Issue owner: V/Line
Operation affected: Rail: Operations control
Date, status, type
Date: 25 Sep 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-007-SI-01Loading rules and procedures
Number: RO-2014-007-SI-01
Description: RO-2014-007-SI-01:The Pacific National freight loading manual, and application of it, was ineffective at preventing loadshift with rod-in-coil product.
Who it affects: All transporters of rod-in-coil product
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 23 Sep 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-021-SI-01Deficient handover process
Number: RO-2014-021-SI-01
Description: RO-2014-021-SI-01:There was a breakdown in the NCO handover process used at Morisset which resulted in ASB being granted to the Protection Officer at Warnervale without the exact location of trains being properly established, signals V8 and V6 being set back to stop and blocking facilities applied in accordance with Network ...
Who it affects: Users the Sydney Trains Network Rules and Procedures
Issue owner: Sydney Trains
Operation affected: Rail: Infrastructure
Date, status, type
Date: 17 Sep 2015
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2015-002-SI-01 Documented instructions
Number: RO-2015-002-SI-01
Description: RO-2015-002-SI-01 :The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment.
Who it affects: All owners, operators and maintainers of railway infrastructure.
Issue owner: Public Transport Authority of Western Australia
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Sep 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-011-SI-01The management of fatigue impairment
Number: RO-2012-011-SI-01
Description: RO-2012-011-SI-01:SBR’s fatigue-management processes were ineffective in identifying the fatigue impairment experienced by the driver leading up to, and at the time of the occurrence.
Who it affects: Rail operators and rail safety workers
Issue owner: Specialised Bulk Rail Pty Ltd
Operation affected: Rail: Freight
Date, status, type
Date: 22 Jun 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-011-SI-02Communication of ‘safety critical information’
Number: RO-2012-011-SI-02
Description: RO-2012-011-SI-02:The ARTC communication protocols did not provide the NCO adequate guidance with respect to standardised phraseology to ensure messages are clear and unambiguous.
Who it affects: Rail operators and rail safety workers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 22 Jun 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-011-SI-03The management of conditional proceed authorities
Number: RO-2012-011-SI-03
Description: RO-2012-011-SI-03:The procedures in the ARTC CoP for the use and verification of a conditional proceed authority were ineffective in mitigating the risk to the effectiveness of that authority arising from human error.
Who it affects: Rail operators and rail safety workers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 22 Jun 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-002-SI-02Track Stability Maintenance Plan
Number: RO-2013-002-SI-02
Description: RO-2013-002-SI-02:There was no Track Stability Management Plan in place for the section of track where the buckle developed – as was required by the ARTC’s CoP.
Who it affects: All track maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 26 May 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-003-SI-001Rail creep management
Number: RO-2014-003-SI-001
Description: RO-2014-003-SI-001:V/Line’s organisational processes for responding to and rectifying rail creep defects did not ensure that all such defects were addressed in a timely way.
Who it affects: All owners of rail infrastructure
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-013-SI-01Safe transition of dual gauge turnouts (Preliminary report)
Number: RO-2014-013-SI-01
Description: RO-2014-013-SI-01:Inherent to the design of many dual gauge turnouts, is a region of reduced wheel rim contact on the broad gauge switch blade (rail head) through the transfer area. In circumstances where the switch blade is insufficiently restrained, and where the passing train has a narrow (127 mm) wheel rim ...
Who it affects: All rail operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status:
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2014-013-SI-02Design of turnouts – MYD882 and MYD887
Number: RO-2014-013-SI-02
Description: RO-2014-013-SI-02:The design of the VCA type 37 mixed gauge turnouts (MYD882 and MYD887) was such that they were not suitable for use by rolling stock with a 127 mm rimmed wheel.
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-013-SI-03Contract approval process
Number: RO-2014-013-SI-03
Description: RO-2014-013-SI-03:Contract documentation and specifications within the Services and Supply Umbrella Agreement were generic and did not adequately specify the intended purpose of the type 37 turnout.
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-013-SI-04Provisional type approval process
Number: RO-2014-013-SI-04
Description: RO-2014-013-SI-04:The VCA type 37 turnout design and V/Line’s provisional type approval process did not fully identify the subtle design changes inherent with the VCA type 37 turnout in determining testing, commissioning and validation needs.
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-013-SI-05Testing of turnouts MYD882 and MYD887
Number: RO-2014-013-SI-05
Description: RO-2014-013-SI-05:The physical testing and commissioning regime for the VCA type 37 turnout did not require the use of standard gauge trains with 127 mm rimmed wheels.
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-013-SI-06Inspection of turnout MYD882 and train wheels
Number: RO-2014-013-SI-06
Description: RO-2014-013-SI-06:V/Line’s processes for responding to the report by the driver of train ST21 did not limit or prevent the subsequent movement of train ST24 before checks had been carried out to identify and assess any potential track and/or rolling stock issue(s).
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-010-SI-01 Track inspection regime
Number: RO-2013-010-SI-01
Description: RO-2013-010-SI-01 :The track inspection regime did not identify the deteriorated rail condition at the O’Tooles Road level crossing. The regime placed an over-reliance on ultrasonic testing and did not include sufficient supplementary systems for monitoring the condition of buried track at unsealed level crossings.
Who it affects: Owners and operators of rail infrastructure
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 29 Apr 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-010-SI-02 Ultrasonic inspection
Number: RO-2013-010-SI-02
Description: RO-2013-010-SI-02 :The ultrasonic testing regime was not effective in consistently identifying corrosion and wasting of the rail web at unsealed level crossings.
Who it affects: Owners and operators of rail infrastructure.
Issue owner: Speno
Operation affected: Rail: Infrastructure
Date, status, type
Date: 29 Apr 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-010-SI-03 Construction of level crossing at unsealed roads
Number: RO-2013-010-SI-03
Description: RO-2013-010-SI-03 :The method of constructing crossings at unsealed roads heightened the potential for corrosion and track degradation and limited the opportunity for effective visual inspection. The network standard for crossing construction did not directly address the particular challenges of unsealed roads.
Who it affects: Owners and operators of rail infrastructure.
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 29 Apr 2015
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-012-SI-01Assessment of the suitability of second-hand components
Number: RO-2014-012-SI-01
Description: RO-2014-012-SI-01:GWA had no documented system in place to assess the suitability of second-hand components for re-use.
Who it affects: All rail infrastructure managers
Issue owner: Genesee Wyoming Australia (GWA)
Operation affected: Rail: Infrastructure
Date, status, type
Date: 28 Apr 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-008-SI-01WOE class wagon, dynamic performance
Number: RO-2014-008-SI-01
Description: RO-2014-008-SI-01:When travelling at speeds near 90 km/h on track having particular track irregularities, the WOE class wagons appear to be susceptible to harmonic oscillations of sufficient magnitude to produce wheel unloading, flange climb and derailment.
Who it affects: All rail transport operators throughout Australia
Issue owner: Aurizon and Brookfield Rail
Operation affected: Rail: Rolling stock
Date, status, type
Date: 26 Mar 2015
Status: Safety action pending
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2014-008-SI-02Increasing train speed
Number: RO-2014-008-SI-02
Description: RO-2014-008-SI-02:After re-railing the track, permitted train speed was increased without due consideration of the effects of cyclic track irregularities on the dynamic performance of the WOE class wagon.
Who it affects: All rail transport operators throughout Australia
Issue owner: Brookfield Rail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 26 Mar 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-008-SI-03Driver reporting and cab ride arrangements
Number: RO-2014-008-SI-03
Description: RO-2014-008-SI-03:The frequency of driver reporting and locomotive cab rides by track inspectors had been insufficient for identifying rough track through the derailment site.
Who it affects: All rail transport operators throughout Australia
Issue owner: Aurizon and Brookfield Rail
Operation affected: Rail: Rolling stock
Date, status, type
Date: 26 Mar 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-008-SI-04Train braking performance
Number: RO-2014-008-SI-04
Description: RO-2014-008-SI-04:The loss of brake pipe integrity during the derailment event did not result in the train brakes automatically activating.
Who it affects: All rail transport operators throughout Australia
Issue owner: Aurizon and Brookfield Rail
Operation affected: Rail: Rolling stock
Date, status, type
Date: 26 Mar 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-006-SI-01 Response to flood event investigations
Number: RO-2014-006-SI-01
Description: RO-2014-006-SI-01 :The ARTC’s processes for developing and implementing changes to operational procedures as a result of incident investigation findings were ineffective at mitigating the risk of future similar incidents.
Who it affects: Rail network managers and train operators
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 25 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-006-SI-02 Management of weather warnings
Number: RO-2014-006-SI-02
Description: RO-2014-006-SI-02 :The ARTC did not have a comprehensive system in place to identify and actively manage risks associated with severe weather events that were likely to affect the safety of their rail network.
Who it affects: Rail network managers and train operators
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 25 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-006-SI-03 Infrastructure flood management
Number: RO-2014-006-SI-03
Description: RO-2014-006-SI-03 :A register for recording ‘special locations’ in accordance with the ARTC Engineering (Track & Civil) Code of Practice - Section 10 – Flooding, had not been established to manage track infrastructure prone to flood damage.
Who it affects: Rail network managers and train operators
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 25 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-015-SI-01Genesee & Wyoming Australia procedures for acceptance of dangerous freight
Number: RO-2014-015-SI-01
Description: RO-2014-015-SI-01:Genesee & Wyoming Australia had no procedure in place to verify (either in total or by random selection) that the nature or condition of freight provided by their customers, complied with their Standard Condition of Carriage.
Who it affects: Rail operators
Issue owner: Genesee & Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 24 Mar 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-018-SI-01Insufficient guidance in Absolute Signal Blocking
Number: RO-2013-018-SI-01
Description: RO-2013-018-SI-01:Rule NWT 308 Absolute Signal Blocking and procedure NPR703 Using Absolute Signal Blocking did not provide any guidance on acceptable methods for determining the location of rail traffic in the section or confirming the clearance of rail traffic past a proposed work location.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-018-SI-02No forms or checklists
Number: RO-2013-018-SI-02
Description: RO-2013-018-SI-02:There were no forms or checklists to provide practical guidance for completing the steps required to implement Absolute Signal Blocking (ASB) or to provide an auditable record of the process.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-018-SI-03Differences in identifying trains
Number: RO-2013-018-SI-03
Description: RO-2013-018-SI-03:Differences exist in the way signallers and Protection Officers (POs) identify trains to each other.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-018-SI-04Infrastructure not marked on ATRICS screen
Number: RO-2013-018-SI-04
Description: RO-2013-018-SI-04:Not all major infrastructure was marked on the ATRICS screens for the North Shore panel.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-018-SI-05Auditing not effective
Number: RO-2013-018-SI-05
Description: RO-2013-018-SI-05:The Sydney Trains regime for auditing worksite protection arrangements was not effective in identifying emerging trends or safety critical issues when using Absolute Signal Blocking (ASB).
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-028-SI-01Special locations
Number: RO-2013-028-SI-01
Description: RO-2013-028-SI-01:Union Reef was not treated as a special location as defined in the ARA Code of Practice for the Australian Rail Network.
Who it affects: All owners and operators of track infrastructure
Issue owner: Genesee and Wyoming Australia
Operation affected: Rail: Infrastructure
Date, status, type
Date: 17 Feb 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-028-SI-02Guidelines
Number: RO-2013-028-SI-02
Description: RO-2013-028-SI-02:The GWA guidance does not provide clear and unambiguous information for train crews on acceptable points approach speeds where sighting distance is reduced
Who it affects: All owners and operators of freight trains
Issue owner: Genesee and Wyoming Australia
Operation affected: Rail: Infrastructure
Date, status, type
Date: 17 Feb 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-028-SI-03Train crew distraction and priorities
Number: RO-2013-028-SI-03
Description: RO-2013-028-SI-03:The train crew had conflicting responsibilities distracting them from the safety critical task of driving. GWA did not have specific policies and procedures to define responsibilities of train crews approaching safety critical phases of operation.
Who it affects: All owners and operators of freight trains
Issue owner: Genesee and Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 17 Feb 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-007-SI-01Track maintenance
Number: RO-2013-007-SI-01
Description: RO-2013-007-SI-01:The ARTC’s inspection and maintenance practices were ineffective at identifying and correcting the deteriorating condition of track infrastructure exhibiting accelerated wear, such as 38A points at Spencer Junction.
Who it affects: All rail safety workers and rolling stock operators
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 Jan 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-027-SI-01Train Control System – design and screen display
Number: RO-2013-027-SI-01
Description: RO-2013-027-SI-01:The Train Control System permitted the NCO to set an unviable route for the train and then displayed it as viable. The train control system alarm designed to alert the NCO to the setting of an unviable route was nullified by the absence of gauge detection.    
Who it affects: ARTC network controllers
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Operations control
Date, status, type
Date: 13 Jan 2015
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-027-SI-02Flaw in Caution Order form
Number: RO-2013-027-SI-02
Description: RO-2013-027-SI-02:A caution order instrument was used that lacked a specific requirement for train crews to check the points along their route. This requirement becomes critical under circumstances of signalling system degradation.
Who it affects: ARTC network controllers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-010-SI-01Maintenance procedures
Number: RO-2014-010-SI-01
Description: RO-2014-010-SI-01:The procedures for locomotive inspection and maintenance were not effective at identifying and addressing continuing fuel leakage problems on this type of fuel filter assembly.
Who it affects: All owners and operators of locomotives
Issue owner: Pacific National and Downer EDI Rail
Operation affected: Rail: Rolling stock
Date, status, type
Date: 31 Oct 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-008-SI-01Sighting restrictions due to road-to-rail angle
Number: RO-2013-008-SI-01
Description: RO-2013-008-SI-01:For eastbound road users approaching the B. McCann Road level crossing along the left-side of the road, the view to the track was restricted due to the acute road-to-rail interface.  This was particularly problematic for trucks with the viewing opportunity to the left limited to the cab’s passenger-side window. 
Who it affects: Users of B. McCann Road level crossing
Issue owner: Cumco Gypsum Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-008-SI-02Rail operator inaction to address identified sighting issues
Number: RO-2013-008-SI-02
Description: RO-2013-008-SI-02:V/Line did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the rail operator in 2009. 
Who it affects: Users of level crossings in Victoria
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-04Road incline on approach to level crossing
Number: RO-2013-008-SI-04
Description: RO-2013-008-SI-04:The road incline on the west-side approach to the crossing increased the time required for loaded trucks to transit the crossing.
Who it affects: Users of B. McCann Road level crossing
Issue owner: Cumco Gypsum Pty Ltd
Operation affected: Rail: Other
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-008-SI-05Crossing protection inconsistent with available sighting
Number: RO-2013-008-SI-05
Description: RO-2013-008-SI-05:The give-way protection installed at the crossing was inconsistent with the available sighting distances on both approaches to the crossing.  Sighting was affected by vegetation, embankments formed by a rail cutting and the curved road approaches. 
Who it affects: Users of B. McCann Road level crossing
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-07ALCAM crossing assessment processes
Number: RO-2013-008-SI-07
Description: RO-2013-008-SI-07:When the crossing was last surveyed under the ALCAM program, the measurement of the road angle resulted in an overestimation of the acute road-to-rail interface angle.  The implication of overestimating the acute interface angle is that sighting deficiencies may be underestimated or not identified.
Who it affects: Stakeholders associated with risk assessment of level crossings
Issue owner: VicTrack
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-08Inconsistency between permitted and published line speed
Number: RO-2013-008-SI-08
Description: RO-2013-008-SI-08:There existed an inconsistency between the track speed used for crossing assessment and permitted train speeds. The ALCAM process used a train speed equal to the track line speed, whereas V/Line systems for evaluating driver behaviour permitted an exceedence of line speed by up to 10 km/h for short distances. 
Who it affects: Stakeholders associated with risk assessment of level crossings
Issue owner: VicTrack
Operation affected: Rail: Other
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-06Level crossing stakeholder consultation
Number: RO-2013-008-SI-06
Description: RO-2013-008-SI-06:The level crossing safety coordination processes did not involve a key stakeholder, the gypsum mine owner, who had knowledge of the changing traffic profile.  The mine owner was aware of the increasing numbers of heavy vehicles using B. McCann Road since 2010 and the associated changing risk profile of the ...
Who it affects: Stakeholders associated with level crossings
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-03Shire inaction to address identified sighting issues
Number: RO-2013-008-SI-03
Description: RO-2013-008-SI-03:Gannawarra Shire did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the Shire in 2009. 
Who it affects: Users of level crossings in Gannawarra Shire
Issue owner: Gannawarra Shire
Operation affected: Rail: Other
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-017-SI-02Non-compliance with repeat back provisions
Number: RO-2013-017-SI-02
Description: RO-2013-017-SI-02:There were non-compliances to the repeat back provision because it was viewed as onerous under certain Local Possession Authorities (LPAs). An opportunity exists to review rule non-conformance with the implementation of LPAs.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 19 Sep 2014
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-017-SI-03Production, validation, customer review and distribution of STNs
Number: RO-2013-017-SI-03
Description: RO-2013-017-SI-03:Sydney Trains validation processes were not effective in detecting errors in Special Train Notice (STN) 1004 prior to the Local Possession Authority (LPA) implementation.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 19 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-06Drug & alcohol management
Number: RO-2012-006-SI-06
Description: RO-2012-006-SI-06:Transfield did not have adequate systems in place to ensure workers were not adversely affected by drugs or alcohol while conducting safety related work in a remote work environment.
Who it affects: Rail – Rail maintenance
Issue owner: Transfield Services Australia
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-02Road-rail vehicle maintenance regime
Number: RO-2012-006-SI-02
Description: RO-2012-006-SI-02:The maintenance regime for Hino TS63 was inadequate and did not account for the accelerated wear and tear on the vehicle when used as a road-rail vehicle.
Who it affects: Track maintenance staff
Issue owner: Transfield Services Australia
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-04Oversight
Number: RO-2012-006-SI-04
Description: RO-2012-006-SI-04:Transfield did not provide oversight sufficient to identify and rectify the non-compliant work practices in the road-rail vehicle operation involved in this occurrence.
Who it affects: Transfield Services Australia
Issue owner:
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-03Training
Number: RO-2012-006-SI-03
Description: RO-2012-006-SI-03:Transfield’s training regime did not ensure that the track workers involved in this occurrence were trained in new or updated work practices relating to road-rail vehicle operations. Similarly, relevant amended procedures, safety bulletins and alerts had not been effectively promulgated to these employees.
Who it affects: Rail – Rail maintenance
Issue owner: Transfield Services Australia
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-05Road-rail vehicle national standards
Number: RO-2012-006-SI-05
Description: RO-2012-006-SI-05:The absence of a national standard that addresses the design, fitment and maintenance of rail guidance equipment and the safety performance for road-rail vehicles while on-rail, increases the risks associated with operating road-rail vehicles.
Who it affects: Rail – Owners and operators of road-rail vehicles
Issue owner: Transfield Services Australia, the Office of National Rail Safety Regulator and the Rail Industry Safety Standards Board
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status:
Type: Proactive Action
  Proactive Action
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-009-SI-02Train control system screen display – incompatible gauge warning
Number: RO-2013-009-SI-02
Description: RO-2013-009-SI-02:When train 9501 approached signal DYN114, which was displaying a Stop indication, there was minimal indication to the network control officer that the train gauge and the selected route were incompatible.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-03Configuration of dual-gauge points assembly
Number: RO-2013-009-SI-03
Description: RO-2013-009-SI-03:The configuration of the dual-gauge points assembly led to a truncated broad-gauge rail in one of the turnout directions.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-04Route knowledge information to train drivers
Number: RO-2013-009-SI-04
Description: RO-2013-009-SI-04:The train operator’s Route Knowledge Package did not include track layout diagrams, or specific information warning of the existence of dual-gauge turnouts where track terminated in one direction.
Who it affects: Rail operators
Issue owner: Pacific National
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-009-SI-05 Indicating the termination of broad-gauge track
Number: RO-2013-009-SI-05
Description: RO-2013-009-SI-05 :There was no warning indication at signal DYN114 to warn train crews that the broad-gauge rail terminated in the straight-ahead direction.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-06Authorising movement past a signal at stop
Number: RO-2013-009-SI-06
Description: RO-2013-009-SI-06:The procedures and guidance documentation for authorising movement past signals displaying a Stop indication was ambiguous.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-07Caution Orders - validating train and route compatibility
Number: RO-2013-009-SI-07
Description: RO-2013-009-SI-07:The process undertaken by the network control officer for issuing a Caution Order does not require validation of compatibility between the train gauge and the established route.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-01Train control system screen display – route information
Number: RO-2013-009-SI-01
Description: RO-2013-009-SI-01:The train control system screen display provided no direct indication to the network control officer that one section of the established route was dual-gauge and another section single-gauge.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2013-021-SI-01Degraded rail joint was not detected
Number: RO-2013-021-SI-01
Description: RO-2013-021-SI-01:V/Line's track inspection regime did not identify the degraded condition of the mechanical rail joints.
Who it affects: All operators of freight trains and infrastructure managers.
Issue owner: V/Line Regional Network and Access
Operation affected: Rail: Infrastructure
Date, status, type
Date: 01 Aug 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-019-SI-01Inconsistency in defining responsibilities for the refuelling of locomotives
Number: RO-2013-019-SI-01
Description: RO-2013-019-SI-01:The instructions relating to the arranging of refuelling at Parkeston contained in the Pacific National train management plan and the intermodal procedures manual were inconsistent.
Who it affects: All rail safety workers and rolling stock operators
Issue owner: Pacific National Pty Ltd
Operation affected: Rail: Freight
Date, status, type
Date: 07 Jul 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-04Training
Number: RO-2013-014-SI-04
Description: RO-2013-014-SI-04:The training provided to the West Coast Wilderness Railway road-rail vehicle operators did not identify and incorporate local specific training requirements, such as operating on very steep grades and the use of radios.
Who it affects: All owners and operators of road-rail vehicles
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Rolling stock
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-05Radio communications
Number: RO-2013-014-SI-05
Description: RO-2013-014-SI-05:Rinadeena Station was the only emergency meeting point between Queenstown and Strahan and the only road access point on the rack between Halls Creek and Dubbil Barril. However, the Rinadeena Station radio was not maintained in a serviceable state at all times.
Who it affects: All track managers
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Operations control
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-08Radio procedures and protocols
Number: RO-2013-014-SI-08
Description: RO-2013-014-SI-08:The West Coast Wilderness Railway did not have documented radio communication procedures and their staff were not trained in the use of radios. As a result, radio protocols were not formalised and communications were ad hoc and casual in nature.
Who it affects: All track managers
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Operations control
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-06Hirail 3 testing and acceptance
Number: RO-2013-014-SI-06
Description: RO-2013-014-SI-06:West Coast Wilderness Railway had not developed and implemented a specification for the design, fitment and safety performance of road-rail vehicle rail guidance equipment.
Who it affects: All owners and operators of road-rail vehicles
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Rolling stock
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-07Documented process for the testing of RRV’s
Number: RO-2013-014-SI-07
Description: RO-2013-014-SI-07:The West Coast Wilderness Railway did not have a documented process of testing road-rail vehicles.
Who it affects: All owners and operators of road-rail vehicles
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Rolling stock
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-009-SI-01Supervision of trainee drivers
Number: RO-2012-009-SI-01
Description: RO-2012-009-SI-01:The Genesee and Wyoming Australia safety management system procedures did not provide supervising and trainee drivers with sufficient guidance or direction as to the extent of their supervisory or permitted driving roles.
Who it affects: All rolling stock operators
Issue owner: Genesee and Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 28 May 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-013-SI-01Independent data, an aid for understanding signalling occurrences
Number: RO-2013-013-SI-01
Description: RO-2013-013-SI-01:The ATSB investigation was unable to substantiate the reported observations of the train crew without having an independent source of data, such as forward facing video on train 5BM7.
Who it affects: All rail operators throughout Australia
Issue owner: Aurizon
Operation affected: Rail: Other
Date, status, type
Date: 05 Mar 2014
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2013-024-S1-01Location of level crossing warning signage
Number: RO-2013-024-S1-01
Description: RO-2013-024-S1-01:On the southern approach to the level crossing, the Stop Sign Ahead (W3-1) warning sign was not located in accordance with the requirements of AS 1742.7-2007 standard.
Who it affects: Users of Pettavel Road level crossing
Issue owner: Surf Coast Shire Council
Operation affected: Rail: Other
Date, status, type
Date: 11 Feb 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-023-SI-01Boundary fence
Number: RO-2013-023-SI-01
Description: RO-2013-023-SI-01:The boundary fence between the railway maintenance access track and Gallagher Road had been removed. As a result, over time and with regular use, the false perception that the maintenance access track was part of Gallagher Road was created and reinforced.
Who it affects: All local councils and track managers
Issue owner: The Australian Rail Track Corporation / Golden Plains Shire
Operation affected: Rail: Infrastructure
Date, status, type
Date: 05 Feb 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-01Management of risk associated with poor adhesion
Number: RO-2013-005-SI-01
Description: RO-2013-005-SI-01:Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion.  
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: Passenger - metropolitan
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-005-SI-03Assessment and recording of rail safety risks
Number: RO-2013-005-SI-03
Description: RO-2013-005-SI-03:Poor wheel/rail adhesion was not recognised as a risk in any of Queensland Rail’s risk registers and therefore this risk to the safety of rail operations was not being actively managed.
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
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-005-SI-04Cross divisional recognition of rail safety risks
Number: RO-2013-005-SI-04
Description: RO-2013-005-SI-04:Despite numerous occurrences of slip-slide events in the years leading up to the accident at Cleveland, Queensland Rail’s risk management processes did not precipitate a broad, cross-divisional, consideration of solutions to the issue including an investigation of the factors relating to poor wheel/rail adhesion.
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
Date, status, type
Date: 20 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-05Application of safety actions from internal investigations
Number: RO-2013-005-SI-05
Description: RO-2013-005-SI-05: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.
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
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-005-SI-07Awareness of rail safety occurrences in other jurisdictions affecting rail fleet type
Number: RO-2013-005-SI-07
Description: RO-2013-005-SI-07:Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in identifying safety issues pertinent to their fleet from rail safety occurrences in other jurisdictions involving poor wheel/rail adhesion.
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
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-08Occurrence notification standard and guideline
Number: RO-2013-005-SI-08
Description: RO-2013-005-SI-08:The national rail occurrence standard and guidelines (ON-S1/OC-G1) do not include significant train wheel slip/slide occurrences as a notification category/type which has the potential to lead to rail safety regulators being unaware of significant and/or systemic safety issues related to wheel/rail adhesion.
Who it affects: Railway safety regulators and railway network owners and operators responsible for the classification and review of railway occurrence notifications.
Issue owner: The Office of the National Rail Safety Regulator
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-09Driver’s manual explanation of effects and control of low adhesion
Number: RO-2013-005-SI-09
Description: RO-2013-005-SI-09:The Queensland Rail driver’s manual did not explain the effects of low adhesion at the wheel/rail interface, how low adhesion is a precursor to prolonged wheel slide events and why these elements reduce the likelihood of achieving expected braking rates.
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
Date, status, type
Date: 20 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-10Effective coordination of emergency communications
Number: RO-2013-005-SI-10
Description: RO-2013-005-SI-10:The successful management of an emergency event from a remote location is critically dependent on clear and effective communication protocols. Communications within train control, and between train control and Cleveland station, were not sufficiently coordinated and resulted in misunderstandings at the Cleveland station accident site.
Who it affects: All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-005-SI-11Emergency management exercises
Number: RO-2013-005-SI-11
Description: RO-2013-005-SI-11:Emergency management simulation exercises to test the preparedness of network control staff, train crew, and station customer service staff to respond cooperatively to rail safety emergencies had not been undertaken in accordance with the Queensland Rail Emergency Management Plan.
Who it affects: All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-12Post emergency debrief and findings
Number: RO-2013-005-SI-12
Description: RO-2013-005-SI-12:The Queensland Rail internal emergency debrief following the Cleveland station collision identified issues related to working with external agencies but did not address critical communication shortfalls within train control and between train control and the staff located at the Cleveland station accident site.
Who it affects: All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-005-SI-06Buffer stop design criterion
Number: RO-2013-005-SI-06
Description: RO-2013-005-SI-06:The mass of the two IMU or SMU class train units travelling on the Cleveland line was commonly heavier than the design specification of the buffer stop at Cleveland station. It is probable that Queensland Rail’s risk management systems did not consider this design criterion for these train configurations arriving ...
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
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-007-SI-01Pedestrian traffic light coordination
Number: RO-2012-007-SI-01
Description: RO-2012-007-SI-01:The Market Street pedestrian crossing traffic lights do not effectively coordinate with the level crossing equipment. When these lights are operating, vehicles can be forced to queue through the roundabout and thus block traffic that is attempting to exit the level crossing while a train is approaching.
Who it affects: All road and rail infrastructure managers
Issue owner: Wyndham City Council
Operation affected: Rail: Infrastructure
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-007-SI-02Level crossing length
Number: RO-2012-007-SI-02
Description: RO-2012-007-SI-02:The level crossing is longer than necessary. Shortening it would reduce the amount of time that a vehicle spends within the crossing and improve the visual information available to motorists when assessing their ability to clear the crossing.
Who it affects: All road and rail infrastructure managers
Issue owner: Metro Trains / Wyndham City Council
Operation affected: Rail: Infrastructure
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: RO-2012-007-SI-03Visual cues
Number: RO-2012-007-SI-03
Description: RO-2012-007-SI-03:Once within the level crossing there are no readily visible cues (like short range lights) to alert a driver that the level crossing protection system is operating.
Who it affects: All rail infrastructure managers
Issue owner: Metro Trains
Operation affected: Rail: Infrastructure
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: RO-2012-007-SI-04Escape or refuge areas
Number: RO-2012-007-SI-04
Description: RO-2012-007-SI-04:There is no available refuge or escape area within the traffic island at the northbound exit of the level crossing.
Who it affects: All road and rail infrastructure managers
Issue owner: Wyndham City Council
Operation affected: Rail: Infrastructure
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-003-SI-03Training for coach/tutor drivers
Number: RO-2013-003-SI-03
Description: RO-2013-003-SI-03:Pacific National Bulk Rail does not provide coach/tutor drivers with sufficient training and direction as to how to perform their role.
Who it affects: All rail operators
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 15 Nov 2013
Status: Adequately addressed
Issue, description, who it affects
Issue: RO-2013-003-SI-01Fatigue management system
Number: RO-2013-003-SI-01
Description: RO-2013-003-SI-01:Pacific National's fatigue management system is over-reliant on the use of a bio-mathematical model to predict individual fatigue risk, being based principally on rostered work hours without due consideration to higher level fatigue risk management strategies.
Who it affects: All rail operators
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 15 Nov 2013
Status: Adequately addressed
Issue, description, who it affects
Issue: RO-2013-003-SI-02Fatigue management training
Number: RO-2013-003-SI-02
Description: RO-2013-003-SI-02:Pacific National Bulk Rail division did not provide training on fatigue management to the driver.
Who it affects: All rail operators
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 15 Nov 2013
Status: Adequately addressed
Issue, description, who it affects
Issue: RO-2013-003-SI-04SPAD strategy
Number: RO-2013-003-SI-04
Description: RO-2013-003-SI-04:Pacific National’s SPAD strategy focuses on individual crew actions and the costs of SPADs, rather than developing integrated error tolerant systems of work with regard for the broader systemic issues known to contribute to SPAD events.
Who it affects: All rail operators
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 15 Nov 2013
Status: Adequately addressed
Issue, description, who it affects
Issue: RO-2013-011-SI-01Level crossing sighting
Number: RO-2013-011-SI-01
Description: RO-2013-011-SI-01:For approaches other than the one taken by this motor vehicle driver, this level crossing did not meet the requirements of Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings.
Who it affects: Users of Brown Street level crossing
Issue owner: Warrnambool City Council
Operation affected: Rail: Other
Date, status, type
Date: 29 Oct 2013
Status: Adequately addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2013-011-SI-02Level crossing signage
Number: RO-2013-011-SI-02
Description: RO-2013-011-SI-02:A review of the signage requirements for compliance with Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings indicated that the Stop Sign Ahead (W3-1) was missing on the northern side of the Brown Street level crossing.
Who it affects: Users of Brown Street level crossing
Issue owner: Warrnambool City Council
Operation affected: Rail: Other
Date, status, type
Date: 29 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-012-SI-01Twist defect detection
Number: RO-2013-012-SI-01
Description: RO-2013-012-SI-01:The twist defect was not detected by TasRail’s inspection/monitoring systems, increasing the risk of derailment.
Who it affects: TasRail
Issue owner: TasRail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-012-SI-02Elevated risk controls
Number: RO-2013-012-SI-02
Description: RO-2013-012-SI-02:TasRail had not instigated proactive action to manage the elevated risks associated with ongoing track stability issues at, or near, the derailment site in accordance with their maintenance procedures.
Who it affects: TasRail
Issue owner: TasRail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-012-SI-03Track inspection intervals
Number: RO-2013-012-SI-03
Description: RO-2013-012-SI-03:Track inspections were not consistently conducted at intervals of not more than 96 hours, in accordance with TasRail’s standard.
Who it affects: TasRail
Issue owner: TasRail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-006-SI-01Management of special locations
Number: RO-2013-006-SI-01
Description: RO-2013-006-SI-01:The ARTC had not instigated proactive action to manage the increased risk of a buckling event in accordance with their procedure ETM-06-06 (Managing Track Stability – Concrete Sleepered Track) at section 1.11.5 - ‘Special Locations’.
Who it affects: All rail infrastructure managers
Issue owner: Australian Rail Track Corporation Limited
Operation affected: Rail: Infrastructure
Date, status, type
Date: 11 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-002-SI-01Response to significant weather events
Number: RO-2012-002-SI-01
Description: RO-2012-002-SI-01:The ARTC’s systems and operational procedures provided limited additional information or guidance to assist network control staff in identifying and assessing a potential threat to the serviceability of the infrastructure resulting from significant weather events.
Who it affects: All rail infrastructure managers
Issue owner: Australian Rail Track Corporation Limited
Operation affected: Rail: Infrastructure
Date, status, type
Date: 30 Aug 2013
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-014-SI-01Risk assessment, procedure and guidelines
Number: RO-2013-014-SI-01
Description: RO-2013-014-SI-01:West Coast Wilderness Railway had not considered all of the risks associated with the operation of road-rail vehicles on the steep railway. As a result, documented operational procedures had not been developed and locations where vehicles could be safely on/off railed had not been defined.
Who it affects: All owners and operators of road rail vehicles
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Operations control
Date, status, type
Date: 15 Aug 2013
Status: Adequately addressed
Type: Proactive Action
  Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2011-009-SI-01Wheel inspection processes
Number: RO-2011-009-SI-01
Description: RO-2011-009-SI-01:The wheel inspection processes prior to the failure of locomotive wheel L4 on SCT 008 were not effective in detecting surface damage or cracks
Who it affects: Rail Rolling stock owners, operators and maintainers
Issue owner: SCT Logistics
Operation affected: Rail: Freight
Date, status, type
Date: 03 Jul 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-009-SI-02Class BM Steel prone to subsurface Cracks
Number: RO-2011-009-SI-02
Description: RO-2011-009-SI-02:Subsurface cracks appeared to be more common on wheels made with Class BM grade steel while operating under conditions of high speed cyclic loading, such as the SCT class locomotives
Who it affects: Rail Rolling stock owners, operators and maintainers
Issue owner: SCT Logistics
Operation affected: Rail: Freight
Date, status, type
Date: 03 Jul 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-003-SI-01Level crossing signage
Number: RO-2012-003-SI-01
Description: RO-2012-003-SI-01:There were some minor non-conformances with the level crossing signage, in particular the ‘Stop’ sign assembly and positioning of the ‘Stop’ line on the western side of the Port Flinders Causeway Road level crossing.
Who it affects: Rail infrastructure managers and maintence personel
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 19 Apr 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-012-SI-01XPT tail pin acceptance
Number: RO-2011-012-SI-01
Description: RO-2011-012-SI-01:RailCorp’s acceptance testing regime for tail pins did not identify that the tail pins stamped BU 06 04 were below standard and, hence, not suitable for service.
Who it affects: Operators of trains with this arrangement of tail pin
Issue owner: RailCorp
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 19 Apr 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-012-SI-02XPT tail pin testing
Number: RO-2011-012-SI-02
Description: RO-2011-012-SI-02:The method used to ultrasonically test the tail pins in-situ was not reliable and resulted in small fatigue cracks going undetected.
Who it affects: Operators of trains with this arrangement of tail pin
Issue owner: RailCorp
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 19 Apr 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-016-SI-01Procedures for supervising drivers
Number: RO-2011-016-SI-01
Description: RO-2011-016-SI-01:Specialised Bulk Rail’s Safety Management System procedures did not provide the supervising drivers with sufficient direction as to the nature of their supervisory role.
Who it affects: All owners and operators of rollingstock
Issue owner: Specialized Bulk Rail (SBR)
Operation affected: Rail: Freight
Date, status, type
Date: 03 Apr 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-016-SI-02Information of the status of learning
Number: RO-2011-016-SI-02
Description: RO-2011-016-SI-02:There were no formalised processes for a driver-in-training to record their experience in learning a route, or to document feedback related to their performance, which could be used by supervising drivers or assessors to assist in mentoring them.
Who it affects: All owners and operators of rollingstock
Issue owner: Specialized Bulk Rail (SBR)
Operation affected: Rail: Freight
Date, status, type
Date: 03 Apr 2013
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-016-SI-03Procedures to attain route knowledge competency
Number: RO-2011-016-SI-03
Description: RO-2011-016-SI-03:Worker competency procedures were deficient in providing a structured program for the development of route knowledge by the driver-in-training.
Who it affects: All owners and operators of rollingstock
Issue owner: Specialized Bulk Rail (SBR)
Operation affected: Rail: Freight
Date, status, type
Date: 03 Apr 2013
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-016-SI-04Fatigue management controls
Number: RO-2011-016-SI-04
Description: RO-2011-016-SI-04:SBR’s process for assessing its drivers’ roster for relay operations relied excessively on a score produced by a bio-mathematical model, and it had limited mechanisms in place to ensure drivers received an adequate quantity and quality of sleep during relay operations.
Who it affects: All owners and operators of rollingstock
Issue owner: Specialized Bulk Rail (SBR)
Operation affected: Rail: Freight
Date, status, type
Date: 03 Apr 2013
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-018-SI-01Authorisation of Control Signal Blocking
Number: RO-2011-018-SI-01
Description: RO-2011-018-SI-01:The rules and procedures governing the issue of a Controlled Signal Block did not require or provide for coordination between network control officers when the Controlled Signal Block affects more than one controller’s area of responsibility.
Who it affects: All track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 27 Mar 2013
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-008-SI-01Assessment of Multiple Geometric Alignment Defects
Number: RO-2011-008-SI-01
Description: RO-2011-008-SI-01:The urgent and priority category defects detected by the AK Car on 4 February 2011 that were located within a 20 m track section were inadequately assessed and controlled in accordance with the ARTC Track and Civil Code of Practice.
Who it affects: Rail Infrastructure Owners and Maintainer
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 21 Jan 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-008-SI-02Exceedence report fields
Number: RO-2011-008-SI-02
Description: RO-2011-008-SI-02:AK Car defect exceedence reports produced on 4 February 2011 did not include fields to record the date and time of follow-up field inspections and to show that these inspections and assessment of defects were completed in accordance with the ARTC Track and Civil Code of Practice.
Who it affects: Managers of Rail Infrastructure
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 21 Jan 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-019-SI-01Policies, procedures and training
Number: RO-2011-019-SI-01
Description: RO-2011-019-SI-01:GWA policies, procedures and training had little if any guidance for employees quantifying the duration, consequential dangers and responses to severe weather events.
Who it affects: Rail infrastructure managers
Issue owner: Genesee & Wyoming Aust Pty Ltd (GWA)
Operation affected: Rail: Freight
Date, status, type
Date: 19 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-019-SI-02Monitoring of severe weather and flood events
Number: RO-2011-019-SI-02
Description: RO-2011-019-SI-02:The warning systems in place to alert GWA staff as to the severity of a flood event at the Edith River Rail Bridge were ineffective.
Who it affects: Rail infrastructure managers
Issue owner: Genesee & Wyoming Aust Pty Ltd (GWA)
Operation affected: Rail: Freight
Date, status, type
Date: 19 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-015-SI-01Documentation and quality control
Number: RO-2010-015-SI-01
Description: RO-2010-015-SI-01:The quality assurance processes used in the acceptance of the Goddards crossing loop project were not sufficiently robust to mitigate the risk of track construction inadequacies.
Who it affects: Rail infrastructure managers and track maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 29 Jun 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-004-SI-01Deficient Track Occupancy Authority Form
Number: RO-2010-004-SI-01
Description: RO-2010-004-SI-01:The ARTC form ANRF-002 (Track Occupancy Authority) was deficient as there was no provision to record critical information regarding the location and type of worksite. Consequently, both the Protection Officer and Network Control Officer incorrectly concluded that the train had passed beyond the limits of the worksite.
Who it affects: Train operations and track maintenance organisations
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Apr 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-004-SI-02Track-side worker training
Number: RO-2010-004-SI-02
Description: RO-2010-004-SI-02:The track workers were not provided with sufficient training (competency based or structured on-job training) in relation to the hazards and required protections for working under the authority in place at Newbridge on 5 May 2010.
Who it affects: Train operations and track maintenance organisations
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Other
Date, status, type
Date: 20 Apr 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-004-SI-03Inconsistency in Track Occupancy Authority procedure
Number: RO-2010-004-SI-03
Description: RO-2010-004-SI-03:The ARTC procedure ANPR-701 (Using a Track Occupancy Authority) was inconsistent in that it did not allow for a scenario that would otherwise be permitted, and intended, under rule ANWT-304 (Track Occupancy Authority).
Who it affects: Train operations and track maintenance organisations
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Other
Date, status, type
Date: 20 Apr 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-004-SI-04Non-authorised Track Occupancy Authority forms
Number: RO-2010-004-SI-04
Description: RO-2010-004-SI-04:Some ARTC maintenance contractors were using non-authorised reproductions of the ARTC’s Track Occupancy Authority form.
Who it affects: Train operations and track maintenance organisations
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Other
Date, status, type
Date: 20 Apr 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-004-SI-05Roster protection against fatigue
Number: RO-2010-004-SI-05
Description: RO-2010-004-SI-05:It was possible that at times throughout the Network Control Officer’s roster, fatigue levels were conducive to performance degradation.
Who it affects: Train operations
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Apr 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-006-SI-02Section Closing and Opening Authority Safety Issue
Number: RO-2011-006-SI-02
Description: RO-2011-006-SI-02:New Section Closing and Opening Authority Telegrams (SCAO) were not completed by the train controller and the Supervisor (Track Machines) for each closing and opening of the track in accordance with WestNet Rule 199.
Who it affects: Employees and contractors
Issue owner: Brookfield Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Apr 2012
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2010-013-SI-01Restricted speed definition
Number: RO-2010-013-SI-01
Description: RO-2010-013-SI-01:The current ARTC definition of restricted speed requires considerable judgement on the part of train drivers.
Who it affects: All track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Other
Date, status, type
Date: 30 Jan 2012
Status: Not addressed
Issue, description, who it affects
Issue: RO-2010-012-SI-01Effects of wind load on rail wagons
Number: RO-2010-012-SI-01
Description: RO-2010-012-SI-01:Double stacked container wagons are at particular risk of wind induced roll-over. This is a direct relationship of exposed side area, and was therefore probably exacerbated by out of gauge/high loads on some wagons with a large surface area exposed to the gust front.
Who it affects: All rail operators
Issue owner: Genesee & Wyoming Aust Pty Ltd (GWA)
Operation affected: Rail: Rolling stock
Date, status, type
Date: 20 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-012-SI-02Identification of severe weather events
Number: RO-2010-012-SI-02
Description: RO-2010-012-SI-02:Train drivers receive no formal training with respect to understanding severe weather events, the associated derailment risk and mitigation strategies.
Who it affects: All rail operators
Issue owner: Genesee & Wyoming Aust Pty Ltd (GWA)
Operation affected: Rail: Freight
Date, status, type
Date: 20 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-011-SI-01Managing the risk of looseness and fretting damage
Number: RO-2010-011-SI-01
Description: RO-2010-011-SI-01:There was no documented evidence that Pacific National actively manages the risk of looseness and fretting damage to bearing components
Who it affects: All owners and operators of rollingstock
Issue owner: Pacific National Pty Ltd
Operation affected: Rail: Rolling stock
Date, status, type
Date: 19 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-002-SI-01Dispatching trains against starting signal
Number: RO-2011-002-SI-01
Description: RO-2011-002-SI-01:Public Transport Services procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.
Who it affects: All rail operators
Issue owner: Rail Commissioner SA
Operation affected: Rail: Operations control
Date, status, type
Date: 11 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-002-SI-02Vigilance control
Number: RO-2011-002-SI-02
Description: RO-2011-002-SI-02:As a defence against driver error Public Transport Services provide their railcars with a vigilance system comprising a deadman’s control and an Automatic Warning System. However, the current system does not protect against ‘Starting against Signal’ SPAD events as occurred at Adelaide Station.
Who it affects: All rail operators
Issue owner: Rail Commissioner SA
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 11 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-002-SI-03SPAD Investigation Form
Number: RO-2011-002-SI-03
Description: RO-2011-002-SI-03:SPAD Investigation Form (RS-ADL-283) used by Public Transport Services does not collect data on many of the human factor issues that would facilitate a better understanding of why SPADs are occurring.
Who it affects: All rail operators
Issue owner: Rail Commissioner SA
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 11 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-002-SI-04Human factors driver training
Number: RO-2011-002-SI-04
Description: RO-2011-002-SI-04:Public Transport Services driver training does not adequately address the risk of distraction and areas of human performance error with respect to SPAD events.
Who it affects: All rail operators
Issue owner: Rail Commissioner SA
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 11 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-002-SI-05Interactive driver training
Number: RO-2011-002-SI-05
Description: RO-2011-002-SI-05:Public Transport Services have not implemented simulator training or a similar interactive system which would allow new drivers to practice, retain and apply what they have learned without the risks associated with driving trains in traffic.
Who it affects: All rail operators
Issue owner: Rail Commissioner SA
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 11 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-002-SI-06Inconsistencies between RoW procedures
Number: RO-2011-002-SI-06
Description: RO-2011-002-SI-06:There are inconsistencies between Right of Way procedures used by platform coordinators and passenger service attendants.
Who it affects: All rail operators
Issue owner: Rail Commissioner SA
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 11 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-002-SI-07Inconsistencies between Work Instructions and the Common General Operating Rules
Number: RO-2011-002-SI-07
Description: RO-2011-002-SI-07:There are inconsistencies between Right of Way Work Instructions and the Common General Operating Rules.
Who it affects: All rail operators
Issue owner: Rail Commissioner SA
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 11 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-002-SI-08Fatigue management
Number: RO-2011-002-SI-08
Description: RO-2011-002-SI-08:Public Transport Services do not have a formal fatigue policy/procedure.
Who it affects: All rail operators
Issue owner: Rail Commissioner SA
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 11 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: Trackside monitoring
Description: Minor Safety IssueExamination of RailBAM® data established that under PN's existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, inspection of the data showed that there was a growing problem with the 2L axle-box.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 28 Sep 2011
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2010-010-SAN-011
Description: Minor Safety IssueAn examination of wheel impact (WILD) data established that under PN's existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, running a trend analysis of WILD data clearly showed that there was a growing wheel impact problem.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 28 Sep 2011
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2010-010-SI-01RailBAM data
Number: RO-2010-010-SI-01
Description: RO-2010-010-SI-01:Examination of RailBAM® data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, inspection of the data showed that there was a growing/trending problem with the 2L axle-box.
Who it affects: All rail operators
Issue owner: Pacific National Pty Ltd
Operation affected: Rail: Rolling stock
Date, status, type
Date: 28 Sep 2011
Status: Adequately addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2010-010-SI-02Wheel impact data
Number: RO-2010-010-SI-02
Description: RO-2010-010-SI-02:An examination of wheel impact (WILD) data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, running a trend analysis of WILD data clearly showed that there was a growing wheel impact problem.
Who it affects: All rail operators
Issue owner: Pacific National Pty Ltd
Operation affected: Rail: Rolling stock
Date, status, type
Date: 28 Sep 2011
Status: Not addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2010-001-SI-01Bearing condition monitoring
Number: RO-2010-001-SI-01
Description: RO-2010-001-SI-01:The wheel bearings on train 2224, consist BT22, were only being monitored in-service by periodic inspections, roll-bys, and hot box detections. These measures were ineffective in detecting the failure of the bearing on train 2224 before it led to the derailment.
Who it affects: All rolling stock operators
Issue owner: Pacific National Pty Ltd
Operation affected: Rail: Rolling stock
Date, status, type
Date: 04 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-001-SI-02Train handling
Number: RO-2010-001-SI-02
Description: RO-2010-001-SI-02:All limestone bulk hopper wagons have been operated up to 15 km/h higher than speeds specified in the Train Operating Conditions Manual, when loaded above 92 t and operated on class 1 or 1C track.
Who it affects: All rolling stock operators
Issue owner: Pacific National Pty Ltd
Operation affected: Rail: Freight
Date, status, type
Date: 04 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-002-SI-01CountryNet Radio System
Number: RO-2010-002-SI-01
Description: RO-2010-002-SI-01:The Manildra Mill shunt locomotive did not have a CountryNet communication system installed as required by the New South Wales Rail Safety (General) Regulation 2008.
Who it affects: All owners and operators of locomotives accessing the interstate rail network in NSW
Issue owner: Manildra Group
Operation affected: Rail: Freight
Date, status, type
Date: 18 May 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: Communication to persons within TOA boundaries
Description: Significant safety IssueRule ANWT 304 does not stipulate that the Protection Officer must inform all persons or work groups who may be within the boundaries of a Track Occupancy Authority of its existence. This is regardless of whether or not these persons or work groups fit the definition of 'work ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 18 Apr 2011
Original risk: Significant
Status:
Type: Recommendation
Issue, description, who it affects
Issue: Communication to persons within Track Occupancy Authority boundaries
Description: Significant safety IssueRule NWT 304 does not stipulate that the Protection Officer must inform all persons or work groups who may be within the boundaries of a Track Occupancy Authority of its existence. This is regardless of whether or not these persons or work groups fit the definition of 'work ...
Who it affects: RailCorp
Issue owner:
Operation affected:
Date, status, type
Date: 18 Apr 2011
Original risk: Significant
Status:
Type: Recommendation
Issue, description, who it affects
Issue: Protection of ‘out of service’ infrastructure
Description: Minor safety IssueThe NSW rules and procedures do not clearly address the requirements relating to protection of 'out of service' track infrastructure.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 18 Apr 2011
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: TOA form ANRF 002
Description: Minor safety IssueThe current TOA form (ANRF 002) does not allow the user to record details of protection measures enacted or whether all persons or work groups within the boundaries of the Track Occupancy Authority have been informed of its existence.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 18 Apr 2011
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2010-007-SI-01Communication to persons within Track Occupancy Authority boundaries
Number: RO-2010-007-SI-01
Description: RO-2010-007-SI-01:Rule ANWT 304 (ARTC) NWT 304 (RailCorp) does not stipulate that the Protection Officer must inform all persons or work groups who may be within the boundaries of a Track Occupancy Authority of its existence. This is regardless of whether or not these persons or work groups fit the definition ...
Who it affects: Rail infrastructure managers and track maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 18 Apr 2011
Status: Adequately addressed
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: RO-2010-007-SI-02Track Occupancy Authority form ANRF 002
Number: RO-2010-007-SI-02
Description: RO-2010-007-SI-02:The current TOA form (ANRF 002) does not allow the user to record details of protection measures enacted or whether all persons or work groups within the boundaries of the Track Occupancy Authority have been informed of its existence.
Who it affects: Rail infrastructure managers and track maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Other
Date, status, type
Date: 18 Apr 2011
Status: Not addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2010-007-SI-03Protection of 'out-of-service' infrastructure
Number: RO-2010-007-SI-03
Description: RO-2010-007-SI-03:The NSW rules and procedures do not clearly address the requirements relating to protection of ‘out of service’ track infrastructure.
Who it affects: Rail infrastructure managers and track maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 18 Apr 2011
Status: Not addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2011-006-SI-01Pre-work briefings
Number: RO-2011-006-SI-01
Description: RO-2011-006-SI-01:At separate pre-work briefings, there was no discussion about train running information and site protection between the Supervisor (Excavators) and the Supervisor (Track Machines).
Who it affects: Employees and contractors
Issue owner: John Holland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 11 Apr 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-006-SI-03Communications Equipment
Number: RO-2011-006-SI-03
Description: RO-2011-006-SI-03:The communications equipment available to the Supervisor (Excavators) was inadequate to effectively communicate with the Supervisor (Track Machines) and with the drivers of the track mounted excavators between Darrine and Jaurdi.
Who it affects: Drivers of the track mounted excavators
Issue owner: John Holland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 11 Apr 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Number: RO-2009-008-SR-034
Description: RO-2009-008-SR-034: Prioritisation of tasks when departing a station yard Significant safety issue There was no RailCorp instruction that specifically referred to the need for train crew to prioritise tasks at safety critical locations or at times when workload is high. Action taken by RailCorp RailCorp has advised that a driver's routine activities include speaking with network control ...
Who it affects: RailCorp
Issue owner:
Operation affected:
Date, status, type
Date: 11 Feb 2011
Status:
Type: Recommendation
Issue, description, who it affects
Issue: RO-2009-008-SI-01Prioritisation of tasks when departing a station yard
Number: RO-2009-008-SI-01
Description: RO-2009-008-SI-01:There was no RailCorp instruction that specifically referred to the need for train crew to prioritise tasks at safety critical locations or at times when workload is high.  
Who it affects: All rail operators
Issue owner: RailCorp
Operation affected: Rail: Rolling stock
Date, status, type
Date: 11 Feb 2011
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2009-008-SI-02Salience of signal JE02
Number: RO-2009-008-SI-02
Description: RO-2009-008-SI-02:The voltage of signal JE02 was below the ARTC standard for the type of globe installed.
Who it affects: Rail infrastructure managers and signal maintenance staff
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 11 Feb 2011
Status: Adequately addressed
Issue, description, who it affects
Issue: RO-2009-008-SI-03Microlok signalling logging capabilities
Number: RO-2009-008-SI-03
Description: RO-2009-008-SI-03:The Microlok signalling program design does not meet the requirements of ARTC signalling standard SCP23 ‘Design of Microlok Interlockings’ in regard to the logging of internal bits that initiate flashing, pulsing or toggled outputs.
Who it affects: Rail infrastructure managers and signal system designers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 11 Feb 2011
Status: Adequately addressed
Issue, description, who it affects
Issue: RO-2010-006-SI-01Check list for verbal authorisation of train movements
Number: RO-2010-006-SI-01
Description: RO-2010-006-SI-01:The ARTC does not have a check list available for network controllers to assist in identifying risks associated with the verbal authorisation of train movements for an integrated yard.
Who it affects: All rail operators
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 24 Jan 2011
Status: No longer relevant
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: Design philosophy
Description: A design based on using a clearance point at the interface of CA74C and CA74D should not have been implemented until it was established that the clearance between the Up Main line and No.1 Platform Road at the interface of CA74C and CA74D tracks was adequate. Safety Advisory Notice The Australian ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Jan 2011
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: 116
Description: 116: Project resourcing Minor safety issue Although the Australian Rail Track Corporation was not resourced to actively participate in the design or commissioning phases of the Cootamundra re-signalling project, greater involvement by the Australian Rail Track Corporation (local knowledge of site geography and layout) during these phases may have assisted the South Improvement Alliance engineers in detecting the ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 20 Jan 2011
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RO-2009-009-SAN-027
Description: RO-2009-009-SAN-027: Project scheduling Minor safety issue As the re-signalling of Cootamundra neared completion it became necessary to undertake control table and software development concurrently to meet the targeted commissioning date. Normally control table and software development is done sequentially to ensure that all the control table logic is fully reflected in the final software and associated validation/testing processes. Action ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 20 Jan 2011
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RO-2009-009-SAN-028
Description: RO-2009-009-SAN-028: On site and pre-commissioning test phase Minor safety issue Where a design involves complex signalling arrangements, may be beneficial to involve the designing engineer during the final onsite field testing phase as they have the best understanding of the interlocking principles. This places them in a strong position to identify any design omissions or deficiencies ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 20 Jan 2011
Original risk: Closed
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-009-SI-01Identification of clearance points
Number: RO-2009-009-SI-01
Description: RO-2009-009-SI-01:The South Improvement Alliance engineers did not effectively identify and record that the interface between CA74C and CA74D was the fouling point between the Up Main line and No.1 Platform Road and thus did not recognise that the rear of a train sitting on the Up Main line at this ...
Who it affects: Rail infrastructure managers and signal system designers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2009-009-SI-02Design philosophy
Number: RO-2009-009-SI-02
Description: RO-2009-009-SI-02:A design based on using a clearance point at the interface of CA74C and CA74D should not have been implemented until it was established that the clearance between the Up Main line and No.1 Platform Road at the interface of CA74C and CA74D tracks was adequate.
Who it affects: Rail infrastructure managers and signal system designers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 Jan 2011
Status: Not addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-009-SI-03Quality control process
Number: RO-2009-009-SI-03
Description: RO-2009-009-SI-03:The documentation and quality control processes used by the South Improvement Alliance for the Cootamundra re-signalling project were not sufficiently robust, in particular, the closing out of identified design issues was inadequate.
Who it affects: Rail infrastructure managers and signal system designers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2009-009-SI-04Project resourcing
Number: RO-2009-009-SI-04
Description: RO-2009-009-SI-04:Although the Australian Rail Track Corporation was not resourced to actively participate in the design or commissioning phases of the Cootamundra re-signalling project, greater involvement by the Australian Rail Track Corporation (local knowledge of site geography and layout) during these phases may have assisted the South Improvement Alliance engineers in ...
Who it affects: Rail infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Jan 2011
Status: Not addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-009-SI-05Project scheduling
Number: RO-2009-009-SI-05
Description: RO-2009-009-SI-05:As the re-signalling of Cootamundra neared completion it became necessary to undertake control table and software development concurrently to meet the targeted commissioning date. Normally control table and software development is done sequentially to ensure that all the control table logic is fully reflected in the final software and associated ...
Who it affects: Signal system designers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 Jan 2011
Status: Partially addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-009-SI-06On site and pre-commissioning test phase
Number: RO-2009-009-SI-06
Description: RO-2009-009-SI-06:Where a design involves complex signalling arrangements, it may be beneficial to involve the designing engineer during the final onsite field testing phase as they have the best understanding of the interlocking principles. This places them in a strong position to identify any design omissions or deficiencies that may not ...
Who it affects: Rail infrastructure managers and signal system designers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Jan 2011
Status: Not addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-009-SI-07Check notes and plan information
Number: RO-2009-009-SI-07
Description: RO-2009-009-SI-07:Where a signalling design has implicit safety requirements that need to be validated onsite, field testers should be provided with comprehensive check notes and/or clearly annotated information that ensures specific testing requirements are not omitted.
Who it affects: Rail infrastructure managers and signal system designers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2009-004-SAN-030
Description: The section of track where train 6MB2 derailed, was previously utilised as the Tottenham standard gauge passing loop. It was not stress tested after slewing and welding when it was converted to mainline operation on 28 July 2008, 5 months before the derailment. Safety Advisory Notice The Australian Transport Safety Bureau ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-004-SAN-032
Description: Measurement of rail creep Regular monitoring and accurate measurement of rail creep was not carried out at the east end of the curve where train 6MB2 derailed in accordance with Civil Engineering Circular 3/87 - 70.2 and 70.3. Creep monuments were not installed on the east end of the curve ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-004-SAN-033
Description: Referenced rail creep punch marks Punch marks were not made on the rail and documented with references to monuments at the 9 km mark following the realignment of track west of the Ashley Street rail bridge. This omission precluded the detection of rail creep that may have been present during ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-004-SAN-031
Description: Documenting of welds on continuous welded railA record of the welds carried out at the 8.351 km point at Tottenham on the 30 January 2009 was not documented in accordance with the requirements of Civil Engineering Circular 3/87. Safety Advisory NoticeThe Australian Transport Safety Bureau advises that the ARTC should consider ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-004-SI-01Stress testing rail following track disturbances
Number: RO-2009-004-SI-01
Description: RO-2009-004-SI-01:The section of track where train 6MB2 derailed, was previously utilised as the Tottenham standard gauge passing loop. It was not stress tested after slewing and welding when it was converted to mainline operation on 28 July 2008, 5 months before the derailment.
Who it affects: Rail Infrastructure Owners and Maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 22 Dec 2010
Status: No longer relevant
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-004-SI-02Measurement of rail creep
Number: RO-2009-004-SI-02
Description: RO-2009-004-SI-02:Regular monitoring and accurate measurement of rail creep was not carried out at the east end of the curve where train 6MB2 derailed in accordance with Civil Engineering Circular 3/87 - 70.2 and 70.3. Creep monuments were not installed on the east end of the curve following the work to ...
Who it affects: Rail Infrastructure Owners and Maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 22 Dec 2010
Status: No longer relevant
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-004-SI-03Referenced rail creep punch marks
Number: RO-2009-004-SI-03
Description: RO-2009-004-SI-03:Punch marks were not made on the rail and documented with references to monuments at the 9 km mark following the realignment of track west of the Ashley Street rail bridge. This omission precluded the detection of rail creep that may have been present during the October 2008 maintenance inspection.
Who it affects: Rail Infrastructure Owners and Maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 22 Dec 2010
Status: No longer relevant
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-004-SI-04Documenting of welds on continuous welded rail
Number: RO-2009-004-SI-04
Description: RO-2009-004-SI-04:A record of the welds carried out at the 8.351 km point at Tottenham on the 30 January 2009 was not documented in accordance with the requirements of Civil Engineering Circular 3/87.
Who it affects: Rail Infrastructure Owners and Maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 22 Dec 2010
Status: No longer relevant
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-003-SAN-019
Description: The ARTC Code of Practice, with respect to Flooding, 'ETG-10-01', does not specify hydrological design parameters, including height of water ponding against the formation layer for a design precipitation event, and this could lead to under specified track drainage arrangements and an increased risk of track damage arising from flash ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 26 May 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-003-SAN-018
Description: The ARTC had not undertaken an audit of track drainage arrangements for the Trans-Australian Railway to verify that the track complied with the relevant standard and that the standard was appropriate. Safety advisory notice The Australian Transport Safety Bureau advises that the Australian Rail Track Corporation should consider the implications of this ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 26 May 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2009-003-SAN-020
Description: At the time of the derailment the ARTC did not have timely access to reliable weather information and may benefit by building closer relationships with the Bureau of Meteorology and local observers (councils, farmers, etc.) who could pass information to assist them with the identification of localised severe weather events ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 26 May 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RO-2008-005-SAN-035
Description: RO-2008-005-SAN-035: Safety issue The process for identifying potential rail defects is limited by the ultrasonic test vehicle operator's ability to detect and assess the echo patterns correctly.   Action taken by the ARTC Rail Technology International (RTI) is actively conducting further development of their ultrasonic testing process. For example, RTI are developing software based on 'Artificial Neural ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 03 Feb 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RO-2008-005-SAN-036
Description: RO-2008-005-SAN-036: Safety Issue The ARTC Code of Practice does not recognise the relationship between heataffected metal and stress concentration when specifying how far a bolt-hole should be from the rail ends before welding. ATSB safety advisory notice RO-2008-005-SAN-036 The Australian Transport Safety Bureau advises that the ARTC should consider the implications of this safety issue and take action ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 03 Feb 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RO-2008-009-SR-029
Description: RO-2008-009-SR-029: Safety issue The ARTC Code of Practice does not clearly address the possibility that a series of track irregularities, even minor ones which do not exceed intervention limits, could cause an undesirable harmonic response in some rail vehicles. ATSB safety recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes safety action to ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 21 Dec 2009
Status:
Type: Recommendation
Issue, description, who it affects
Number: RO-2008-009-SR-030
Description: RO-2008-009-SR-030: Safety Issue The trailing bogie of wagon RCPF-31882C was found to have loose and broken wedge wear plates. It could not be verified whether the wedge wear plates had broken free before or during the derailment sequence. However, if the condition had existed prior to the derailment, it is likely that body roll induced while ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 21 Dec 2009
Status:
Type: Recommendation
Issue, description, who it affects
Number: RO-2008-009-SR-031
Description: RO-2008-009-SR-031: Safety issue Examination of wagon RCPF-31882C revealed a crack on the tread of a wheel on the second axle of the leading bogie. While not contributing to this derailment, if the crack were to develop to such an extent that the wheel tread completely fractured, the risk of derailment would increase significantly. Safety recommendation The Australian Transport ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 21 Dec 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: RO-2009-002-SR-011
Description: Safety issue Manual systems of train management, such as Special Proceed Authority working, are used when interlocked/engineered systems are not available. However, manual systems are subject to human error and increase the risk of safeworking irregularities/incidents when compared to interlocked/engineered systems of safeworking. Response from the ARTC Special Proceed Authorities (SPAs) are a ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 11 Dec 2009
Status:
Type: Recommendation
Issue, description, who it affects
Number: RO-2008-001-SR-021
Description: RO-2008-001-SR-021:Safety Issue At the time of the collision, the Australian Rail Track Corporation and the Port Adelaide Enfield Council did not have an interface coordination plan to manage the risks associated with the Stirling Street level crossing interface, including the installation and maintenance of pavement marking. Safety recommendation The Australian Transport Safety Bureau ...
Who it affects: Port Adelaide Enfield City Council
Issue owner:
Operation affected:
Date, status, type
Date: 06 Oct 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: RO-2008-001-SR-025
Description: At the time of the collision, the Australian Rail Track Corporation and the Port Adelaide Enfield Council did not have an interface coordination plan to manage the risks associated with the Stirling Street level crossing interface, including the installation and maintenance of pavement marking. Safety recommendation The Australian Transport Safety Bureau recommends ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 06 Oct 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: RO-2008-001-SR-026
Description: Safety Issue The Australian Rail Track Corporation had not been approached as part of the SA Department for Transport, Energy and Infrastructure's (DTEI) process of issuing Heavy Vehicle Permits for routine 'fixed term' Restricted Access Vehicle operations. Consequently, the process may preclude the opportunity to determine all risks associated with a ...
Who it affects: Department for Transport, Energy and Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 06 Oct 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: RO-2007-006-SR-008
Description: There was no record to indicate that a worn section of rail, inserted into the track on 25 July 2007, was tested as being suitable for reuse as prescribed in the WestNet Rail Standard Gauge Mainline Code of Practrice. The lack of construction and maintenance documentation compromises the ability to ...
Who it affects: WestNet Rail
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: RO-2007-006-SR-009
Description: There was no clear guidance within the WestNet Rail rules for train crews that defined an allowable speed associated with proceeding 'cautiously'. Had the train been travelling at a slower speed it is probable that the extent of damage caused by the derailment would have been less. Action taken by WestNet ...
Who it affects: WestNet Rail
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: RO-2008-004-SR-011
Description: A single extra pulse echo was recorded during the last ultrasonic inspection of the rail, nine months before the derailment, in the vicinity of the failure. An examination with handheld ultrasonic testing equipment at the time concluded there was no sizable defect in the rail, even though the evidence suggests ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 19 Jun 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: RO-2008-004-SR-012
Description: Unused bolt-holes in the rail web are sufficient stress concentrators to result in the initiation and propagation of fatigue cracking, ultimately leading to the failure of the rail. Action taken by the ARTCThe ARTC has introduced a common standard for bolt-hole crack limits across the whole ARTC network. The standard has ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 19 Jun 2009
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080034
Description: RR20080034: Safety Issue The railway 'Stop' sign assembly (RX-2 modified) for drivers entering Murrow Farm, was not located on the left side of the road to assist with driver familiarity and standard placement of signs as shown in Australian Standard AS 1742.7-2007. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation take action ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 28 Aug 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080035
Description: RR20080035: Safety Issue The railway 'Stop' sign assembly (RX-2 modified) positioned approximately 4.6 m from the nearest rail instead of nearer to 3.5 m as recommended in Australian Standard AS 1742.7, made it more difficult for the driver to gain a clear view of approaching trains. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 28 Aug 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080036
Description: RR20080036: Safety Issue At the time of the accident the Australian Rail Track Corporation and the District Council of Mallala did not have an 'Interface Agreement' defining each organisation's responsibilities with respect to the maintenance of level crossings and land adjoining the rail corridor in the district. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 28 Aug 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080037
Description: RR20080037: Safety Issue At the time of the accident the District Council of Mallala and the Australian Rail Track Corporation did not have an 'Interface Agreement' defining each organisation's responsibilities with respect to the maintenance of level crossings and land adjoining the rail corridor in the district. Safety Recommendation The Australian Transport Safety Bureau recommends that the District Council ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 28 Aug 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080032
Description: RR20080032: Safety Issue Tree pruning and clearing works following the identification of a sighting hazard at the Murrow Farm level crossing in March 2007 were not completed within 28 days in accordance with the original assessment and priority maintenance specification. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation take action to address ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Aug 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080033
Description: RR20080033: Safety Issue Downgrading of the ARTC Infrastructure Management System priority rating for sighting restoration work at the Murrow Farm level crossing, in this case from 28 days to 180 days, without a reassessment of the status of vegetation at the level crossing and its effect on sighting distances, increased the risk of a collision. Safety Recommendation The Australian ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 20 Aug 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR2008003SR004
Description: RR2008003SR004: Safety Issue There was insufficient sighting distance of the Down distant signal and insufficient distance between the Down distant signal and Down outer home signal at Gloucester to allow train 2WB3 to stop at the Down outer home signal from the permitted track speed of 70 km/h. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 15 Aug 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR2008003SR005
Description: RR2008003SR005: Safety Issue ARTC procedures for managing limit of authority over-runs by trains appear to be inconsistent with the applicable network rule as they do not mandate an immediate emergency call from the train control centre to the train crew as the first response. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Railway Track Corporation ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 15 Aug 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080031
Description: RR20080031: Safety Issue No recorded data was available to the investigation because the recording devices were destroyed in the fire which resulted from the collision. Safety Recommendation The Australian Transport safety Bureau recommends that Pacific National take action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 31 Jul 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080029
Description: RR20080029: Safety Issue It is unlikely that the combined effects of the track geometry defects were considered when assessing a track speed suitable for safe rail operations, especially considering that the horizontal alignment defect was below the documented defect limits and associated response codes. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080030
Description: RR20080030: Safety Issue It is unlikely that the dynamics of poorer riding rolling stock were considered when assessing the track geometry defect and determining a suitable speed limit for train operations. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes safety action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080026
Description: RR20080026: Safety Issue During the investigation it was noted that the Moloney Road level crossing had a history of collisions and near misses. A mechanism should be considered to flag for attention, level crossings that have not been identified as posing a high risk when assessed using the ALCAM but have a history of incidents and/or accidents. Safety ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 27 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080027
Description: RR20080027: Safety Issue During the investigation it was noted that the Australian Rail Track Corporation and the City of Playford Council did not have an 'Interface Agreement' covering their responsibilities with respect to the maintenance of level crossing signage. Maintenance responsibilities need to be clearly defined. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 27 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080028
Description: RR20080028: Safety Issue The sounding of the locomotive horn was not at the whistle board as prescribed, however there was time for the truck driver to take defensive action had he heard it. Safety Recommendation The Australian Transport Safety Bureau recommends that Pacific National take action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 27 Jun 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080021
Description: RR20080021: Safety Issue The Works Infrastructure compliance officer (with overall planning responsibility for ensuring that the overpass work site was appropriately protected from train movements) and the North Geelong 'C' signalbox signaller implemented a method of safeworking based on section 15, rule 5 of the network rules. The variation in safeworking arrangements was not formally communicated to McElligott's, ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 08 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080022
Description: RR20080022: Safety Issue The intent of section 15, rule 5 of the network rules was misconstrued by the Works Infrastructure compliance officer and the North Geelong 'C' signalbox signaller in protecting the Separation Street overpass work site. Their interpretation of section 15, rule 5 introduced the risk of a miscommunication and single person error. It relied totally ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 08 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080023
Description: RR20080023: Safety Issue The Works Infrastructure compliance officer (with overall planning responsibility for ensuring that the overpass work site was appropriately protected from train movements) and the North Geelong 'C' signalbox signaller implemented a method of safeworking based on section 15, rule 5 of the network rules. The variation in safeworking arrangements was not formally communicated to McElligott's, ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 08 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080024
Description: RR20080024: Safety Issue The intent of section 15, rule 5 of the network rules was misconstrued by the Works Infrastructure compliance officer and the North Geelong 'C' signalbox signaller in protecting the Separation Street overpass work site. Their interpretation of section 15, rule 5 introduced the risk of a miscommunication and single person error. It relied totally ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 08 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080025
Description: RR20080025: Safety Issue Section 15, rule 5 of the network rules is only applicable for 'Two Position Lower Quadrant Signalling' areas and should not have been used at the Separation Street overpass work site which had 'Three Position Signalling'. Further, section 15, rule 5 stipulates additional but unspecified levels of site protection by the 'Ganger'. The level ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 08 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: R2007014SR029
Description: R2007014SR029: Safety issue The company operations manual provided limited guidance to assist pilots in their weather-related decision-making during the preparation for, and conduct of flights. Operator comment During the investigation and its consideration of the draft report, the operator indicated that it would consider the development of procedures that would support pilots' weather-related decision-making during the preparation for, and conduct ...
Who it affects: Kimberly Seaplanes
Issue owner:
Operation affected:
Date, status, type
Date: 01 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: R2007014SR030
Description: R2007014SR030: Safety issue The company operations manual did not specify any recovery procedures in the event of inadvertent entry into Instrument Meteorological Conditions (IMC). Operator comment During the investigation and consideration of the draft report, the operator indicated that it would develop procedures for application by pilots in the event of inadvertent entry into IMC for inclusion in its ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 01 May 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR2008-006-SR-007
Description: RR2008-006-SR-007: Safety Issue There were no mechanical deficiencies with the locomotives. However locomotive data log information was not isolated or correctly preserved and as a result the data was corrupted or overwritten. This issue occurred as a result of inadequate training of maintenance personnel in the servicing and extraction of data from data logging devices installed ...
Who it affects: Genesee & Wyoming Australia
Issue owner:
Operation affected:
Date, status, type
Date: 08 Apr 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RS2008004
Description: RS2008004: Safety Issue Network rules and procedures were deficient with respect to ensuring that back-up communication details were routinely recorded on train control graphs to allow for a seamless transfer in the event of primary communications failure. Safety Advisory Notice The Australian Transport Safety Bureau advises that all track managers in New South Wales should consider the safety ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 08 Mar 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RR20080016
Description: RR20080016: Safety Issue GrainCorp's procedures were not sufficiently clear with respect to the use of the CountryNet system as the primary communication system. Further, it was evident that the organisation's policy with respect to train communications actively encouraged the routine use of secondary communication systems by their train crews. Safety Recommendation The Australian Transport Safety Bureau recommends that ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Mar 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080017
Description: RR20080017: Safety Issue GrainCorp's train crew change over procedures did not ensure that the status of train 9351's LocoLAN radio was checked as being activated and registered during the crew changeover at Goulburn and thus led to the train continuing its journey without being registered on the CountryNet communication system. Safety Recommendation The Australian Transport Safety Bureau recommends ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Mar 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080018
Description: RR20080018: Safety Issue Network rules and procedures were deficient with respect to ensuring the registration of leading locomotive radios on the CountryNet communication system prior to departure. This increased the risk of trains entering the network without being registered on the CountryNet communication system and therefore not being contactable using the primary communications system during emergencies. Action taken by/response ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Mar 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080019
Description: RR20080019: Safety Issue Network rules and procedures were deficient with respect to ensuring that back-up communication details were routinely recorded on train control graphs to allow for a seamless transfer in the event of primary communications failure. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation take action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Mar 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RS2008001
Description: RS2008001: Safety Issue GrainCorp's procedures were not sufficiently clear with respect to the use of the CountryNet system as the primary communication system. Further, it was evident that the organisation's policy with respect to train communications actively encouraged the routine use of secondary communication systems by their train crews. Safety Advisory Notice The Australian Transport Safety Bureau advises ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Mar 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RS2008002
Description: RS2008002: Safety Issue GrainCorp's train crew change over procedures did not ensure that the status of train 9351's LocoLAN radio was checked as being activated and registered during the crew changeover at Goulburn and thus led to the train continuing its journey without being registered on the CountryNet communication system. Safety Advisory Notice The Australian Transport Safety Bureau ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Mar 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RS2008003
Description: RS2008003: Safety Issue Network rules and procedures were deficient with respect to ensuring the registration of leading locomotive radios on the CountryNet communication system prior to departure. This increased the risk of trains entering the network without being registered on the CountryNet communication system and therefore not being contactable using the primary communications system during emergencies. Safety Advisory Notice The ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Mar 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RR20080020
Description: RR20080020: Safety Issue Considering the profile of the displaced shoulder ballast and the absence of any evidence to the contrary, it is possible that the combined effects of wind load, due to the prevailing thunderstorm conditions, and the wagons' natural oscillations while travelling, could have been sufficient to initiate the overturning of the lightly loaded, double stacked, ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080013
Description: RR20080013: Safety Issue The design tolerances during the construction of the underframe and draft sill area may have been exceeded on some CQBY wagons. In the case of the failed coupler on wagon CQBY 0118A, this was evidenced by signs of biased wear on the coupler wear plate and contributed to excessive hard contact and wear ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 21 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080014
Description: RR20080014: Safety Issue A horizontal misalignment of the slots in the coupler, yoke and draft sill allowed the coupler to grab the draft key and move it laterally applying a heavily biased lateral force to the draft key, anti-wear collar and retainer pin. These forces ultimately resulted in the retainer pin split pin failing, the retainer ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 21 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080015
Description: RR20080015: Safety Issue Where Azee type draft key retainer pins have been fitted to CQBY wagons maintenance programs should be reviewed to ensure existing or revised inspection intervals are appropriate for these items. Safety Recommendation The Australian Transport Safety Bureau recommends that the Chicago Freight Car Leasing Australia take action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 21 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080003
Description: RR20080003: Safety issue Regulatory requirements for commercial drivers in the road-train truck driver's age group dictate that every five years MC class licence holders are required to undergo a vision test. More extensive medical assessments are required only when a condition is reported by a health professional or self reported by the licence holder. Safety Recommendation The Australian Transport ...
Who it affects: National Transport Commission and jurisdictions
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080004
Description: RR20080004: Safety issue The evidence is that the road traffic control measure of 'stop and give-way to trains' at the Fountain Head Road level crossing, Ban Ban Springs, was not being complied with by a number of road vehicle drivers before the accident on 12 December 2006. Action taken The Northern Territory Department of Planning and Infrastructure have ...
Who it affects: Northern Territory Department of Planning and Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080006
Description: RR20080006: Safety Issue Road markings on the southern approach to the Fountain Head Road level crossing were either faded to a point where they could not be seen or were missing altogether. 'Sign clutter' on the northbound approach to the level crossing lessened the visibility of the advance level crossing warning sign. Safety Recommendation The Australian Transport Safety ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080007
Description: RR20080007: Safety issue The portable satellite telephone carried in the lead locomotive of The Ghan was the only means of communication (in close proximity) that the train drivers had once the locomotives were shut down. This satellite telephone worked intermittently at best. Safety Recommendation The Australian Transport Safety Bureau recommends that Pacific National takes action to address this safety ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080008
Description: RR20080008: Safety issue Notwithstanding the communication difficulties and the trauma being experienced by the train drivers, notification of the accident to the Pacific National Divisional Control Centre was practically immediate and subsequent updates regular. However, notification to the Genesee Wyoming Australia Train Control Centre was not as timely and updates not as regular. Safety Recommendation The Australian Transport Safety ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080009
Description: RR20080009: Safety issue The data logger on the lead locomotive of The Ghan was not recording several key parameters correctly (or at all). Safety Recommendation The Australian Transport Safety Bureau recommends that Pacific National takes action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080010
Description: RR20080010: Safety issue The time stamps on the voice transcripts at the Pacific National Divisional Control Centre were inaccurate by a wide margin. Safety Recommendation The Australian Transport Safety Bureau recommends that Pacific National takes action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080011
Description: RR20080011: Safety issue The time stamps on the voice transcripts at the Genesee and Wyoming Adelaide Train Control Centre were inaccurate by a wide margin. Safety Recommendation The Australian Transport Safety Bureau recommends that Genesee and Wyoming Australia takes action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080012
Description: RR20080012: Safety Issue The passenger survey indicated that the majority of passengers (who responded to the survey) did not know where the emergency exits or door keys were located. A slight majority of these respondents (57 per cent) did not remember receiving (or could not remember the contents of) the safety information that was given at the ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080005
Description: RR20080005: Safety issue The remoteness of much of the Northern Territory rail corridor and the local climatic conditions could make a timely response to an accident challenging in some circumstances, particularly in the wet season. Action taken Northern Territory Rail Safety Committee coordinated a desktop emergency exercise in 2006 and an emergency field exercise of a simulated level crossing ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080001
Description: RR20080001: Safety Issue The unrestricted speed of train 3AB6 on a relatively hot day provided sufficient dynamic force to cause the track, with its diminished stability, to misalign. The current imposition of precautionary temperature-related speed restrictions recognises maximum temperature extremes but does not allow for a situation where daily temperature variations (minimum to maximum) are significant. Safety Recommendation The Australian ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jan 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20080002
Description: RR20080002: Safety Issue The random wide pattern installation of steel sleepers that existed at Yerong Creek can cause localised variations in track stiffness which can impact on the riding qualities of rollingstock resulting in an increase in forces, including lateral forces. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes action to ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jan 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: RS2007003
Description: RS2007003: Safety Issue The track had been maintained based on the assumption that rail creep is sufficiently homogenous in open track to be manageable if monitored at 500 m intervals. It is likely that the rail creep in the area of the derailment was not homogenous as a result of long term and recent track work. ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jan 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RR20070032
Description: RR20070032: Safety Issue TransAdelaide's SPAD investigation process was unlikely to have provided a clear understanding of factors that may have contributed to past SPADs or a sound basis for identification of safety actions to prevent similar occurrences. A recommended action in TransAdelaide's SPAD risk management plan was the establishment of a SPAD investigation group to investigate individual ...
Who it affects: TransAdelaide
Issue owner:
Operation affected:
Date, status, type
Date: 20 Dec 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070033
Description: RR20070033: Safety Issue It is possible that departure procedures at Adelaide station could increase the risk of 'Starting Against Signal' SPADs due to expectation error. Platform coordinators give RoW at the scheduled departure time regardless of any delay to clearing the departure signal. Under these conditions, it is possible that drivers would move off and slowly approach ...
Who it affects: TransAdelaide
Issue owner:
Operation affected:
Date, status, type
Date: 20 Dec 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070028
Description: RR20070028: Safety Issue On the day of the commissioning, the engineer and technician had been awake in excess of 14 and 12 hours respectively. The commissioning works required sustained levels of concentration which meant both men were probably suffering from some degree of cognitive fatigue at the end of the day when they inadvertently left the temporary ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 14 Nov 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070029
Description: RR20070029: Safety Issue The 'Test & Commissioning Plan' was deficient in that it did not adequately address the split of responsibilities between the engineer (responsible for managing the wiring alteration process) and the technician (for facilitating train safeworking and implementing WNR's signalling policies and procedures). This uncertainly may have led to some confusion regarding the ownership of important ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 14 Nov 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070030
Description: RR20070030: Safety Issue At least one approach warning sign (RX-7 assembly) had not been installed on the Forrest Street/north-west approach to the Chapple Street level crossing. Safety Recommendation The Australian Transport Safety Bureau recommends that Kalgoorlie-Boulder City Council take action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 14 Nov 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070031
Description: RR20070031: Safety Issue There were no mechanical deficiencies with the train, however the data recorded by the locomotive logger was corrupt, probably as a result of poor maintenance. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Railroad Group take action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 14 Nov 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070023
Description: RR20070023: Safety Issue It is likely that motorists who traverse the Barpinba-Poorneet Road level crossing regularly fail to come to a halt at the 'Stop' signs.   Safety Recommendation The Australian Transport Safety Bureau recommends that the Victorian Department of Infrastructure10 take action to address this safety issue. ___________________ 10. The Victorian Rail system operates on the principle of 'co-regulation'. The state ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 24 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070024
Description: RR20070024: Safety Issue The difficult viewing angle imposed by this site (coupled with the truck not stopping and the restricted visibility from the truck driver's cab) meant that there was little opportunity for the truck driver to see and avoid a collision with the train.   Safety Recommendation The Australian Transport Safety Bureau recommends that the Department of Infrastructure ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 24 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070025
Description: RR20070025: Safety Issue During the investigation it was noted that the Australian Rail Track Corporation and the Colac Otway Shire Council did not have an 'Interface Agreement' covering their respective maintenance responsibilities. Maintenance responsibilities need to be clearly defined. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation take action to address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 24 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070026
Description: RR20070026: Safety Issue The approach warning signage on the south west approach of the Barpinba- Poorneet Road level crossing was not compliant with AS1742.7-1993 and in poor repair. A motorist unfamiliar with the road would probably be unaware of the level crossing until they could directly sight it. Safety Recommendation The Australian Transport Safety Bureau recommends that the ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 24 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070027
Description: RR20070027: Safety Issue During the investigation it was noted that the Australian Rail Track Corporation and the Colac Otway Shire Council did not have an 'Interface Agreement' covering their respective maintenance responsibilities with respect to the maintenance of level crossing signage. Maintenance responsibilities need to be clearly defined. Safety Recommendation The Australian Transport Safety Bureau recommends that the Colac Otway ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 24 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RS20070002
Description: RS20070002: Safety Issue Although train conspicuity may not have been a significant factor in this collision, rollingstock operators should examine opportunities to enhance train visibility to ensure that road users can better see approaching trains (locomotives or carriages), or trains that are already on a railway level crossing. Safety Advisory Notice The Australian Transport Safety Bureau advises that ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 24 Oct 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RS20070001
Description: RS20070001: Safety Issue Tests conducted on 53.5 m long B+2A road-trains at the Fountain Head Road level crossing, Ban Ban Springs, found that the procedure/standard used to calculate and/or assess the level crossing sighting distance was probably inadequate for the truck configuration tested. It is likely that sighting distances at other level crossings controlled by Stop signs, ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 05 Oct 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: RR20070003
Description: RR20070003: Safety Recommendation The ATSB recommends that the NSW Level Crossing Strategy Council consider strategies to reinforce public awareness of the risks associated with cannabis use and the resultant impairment of driving performance, and driver distraction in relation to mobile telephone ringing and usage.
Who it affects: NSW Level Crossing Strategy Council
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070015
Description: RR20070015: Safety Recommendation The ATSB recommends that the Australian Rail Track Corporation consider the benefits of pre briefing or warning train crews (by radio) about timetabled and also non-scheduled train crosses.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070016
Description: RR20070016: Safety Recommendation The ATSB recommends that Chicago Freight Car Leasing Australia review the effectiveness of their current fixed time based train driver vigilance systems with a view to ensuring that drivers maintain an optimal state of alertness at all times while performing driving duties.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070017
Description: RR20070017: Safety Recommendation The ATSB recommends that Interail monitor and review processes in place to ensure that train crews are competent to undertake work at their designated level of responsibility and that this is acknowledged and recorded within the employee files. (For example, evidence that demonstrates requisite driver safeworking and route knowledge skills.)
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070018
Description: RR20070018: Safety Recommendation The ATSB recommends that Interail monitor and review processes in place to ensure that driver re-certification is regularly reviewed and recorded.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070019
Description: RR20070019: Safety Recommendation The ATSB recommends that Interail review their current crew resource management practices with a view to ensuring that a co-driver is sufficiently alert and actively participating in the operation of the train, particularly during periods of high risk operation.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070020
Description: RR20070020: Safety Recommendation The ATSB recommends that Interails training strategies clearly articulate and communicate mentoring responsibilities and what this entails. (For example, the responsibility of a Level 4 driver in managing a Level 3 driver.)
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070021
Description: RR20070021: Safety Recommendation The ATSB recommends that Interail should review opportunities to improve its systems that identify weaknesses in driver safeworking and route knowledge skills and improve fatigue management to ensure drivers are fully fit for duty.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070013
Description: RR20070013: Safety Recommendation The NT Level Crossings Safety Committee should consider further strategies to reinforce public awareness of risk and encourage safe motorist behaviour at railway level crossings.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 28 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070014
Description: RR20070014: Safety Recommendation FreightLink should consider strategies to make approaching trains more conspicuous to motorists stopped at, or approaching, railway level crossings.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 28 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070022
Description: RR20070022: Safety Recommendation The Australian Transport Safety Bureau recommends that RailCorp review its maintenance procedures with respect to XPT axles with a view to eliminating, or mitigating to the maximum extent practicable, the risk of a fatigue crack initiating and propagating to point of causing an axle failure.
Who it affects: RailCorp
Issue owner:
Operation affected:
Date, status, type
Date: 28 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070004
Description: RR20070004: Safety Recommendation The ATSB recommends that the Australian Rail Track Corporation (ARTC) examine opportunities with Genesee & Wyoming Aust. Pty. Ltd. (GWA) and the Coorong District Council (CDC) for reducing the road/rail interface risk at the Magpie Drive level crossing13. This should include opportunities for closure of the crossing and/or realignment strategies that will improve both ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070005
Description: RR20070005: Safety Recommendation The ATSB recommends that Genesee & Wyoming Aust. Pty. Ltd. (GWA) examine opportunities with the Australian Rail Track Corporation (ARTC) and the Coorong District Council (CDC) for reducing the road/rail interface risk at the Magpie Drive level crossing13. This should include opportunities for closure of the crossing and/or realignment strategies that will improve both sighting ...
Who it affects: Genesee & Wyoming Aust. Pty. Ltd.
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070006
Description: RR20070006:Safety Recommendation The ATSB recommends that the Australian Rail Track Corporation improve communications with Genesee & Wyoming Aust. Pty. Ltd. and the Coorong District Council in relation to the inspection and maintenance of level crossings, including the development of a formal 'Level Crossing Interface Agreement' that adequately addresses their specific responsibilities ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070007
Description: RR20070007: Safety Recommendation The ATSB recommends that South Spur Rail Services examine opportunities for enhancing the conspicuity of its locomotives.
Who it affects: South Spur Rail Services
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070008
Description: RR20070008: Safety Recommendation The ATSB recommends that the Australian Rail Track Corporation improve communications with Genesee & Wyoming Aust. Pty. Ltd. and the Coorong District Council in relation to the inspection and maintenance of level crossings, including the development of a formal 'Level Crossing Interface Agreement' that adequately addresses their specific responsibilities and requirements of AS 4292.114 Section 7 ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070009
Description: RR20070009:Safety Recommendation The ATSB recommends that the Genesee & Wyoming Aust. Pty. Ltd. improve communications with the Australian Rail Track Corporation and the Coorong District Council in relation to the inspection and maintenance of level crossings, including the development of a formal 'Level Crossing Interface Agreement' that adequately addresses their specific ...
Who it affects: Genesee & Wyoming Aust. Pty. Ltd.
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070010
Description: RR20070010:Safety Recommendation The ATSB recommends that the Coorong District Council improve communications with the Australian Rail Track Corporation and Genesee & Wyoming Aust. Pty. Ltd. in relation to the inspection and maintenance of level crossings, including the development of a formal 'Level Crossing Interface Agreement' that adequately addresses their specific responsibilities ...
Who it affects: Coorong District Council
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070011
Description: RR20070011: Safety Recommendation The ATSB recommends that the Coorong District Council develop a program for the regular inspection of all level crossings in the district to ensure that road alignment, markings and signage conform to Australian Standard AS1742.7, Manual of Uniform Traffic Control Devices, Part 7: Railway Crossings.
Who it affects: Coorong District Council
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070012
Description: RR20070012: Safety Recommendation The ATSB recommends that the Department for Transport, Energy and Infrastructure examine opportunities to expand the role of the Level Crossing Unit to include some form of auditing role to better oversight the management of risk mitigation strategies employed by road authorities/councils and railway owners at level crossings in order to monitor the effectiveness ...
Who it affects: Department for Transport, Energy and Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 15 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070002
Description: RR20070002: Safety Recommendation Pacific National review train handling practices and/or procedures to ensure drivers are prepared to stop in all circumstances when approaching anticipated track works.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 27 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20070001
Description: RR20070001: Safety Recommendation The ARTC should review their policies and/or procedures to ensure that factors such as the type and speed of train traffic and the gradient of the line are adequately considered when placing outer flag persons to protect track-work sites.
Who it affects: ARTC
Issue owner:
Operation affected:
Date, status, type
Date: 26 Mar 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR2006048
Description: RR2006048: Safety Recommendation The Australian Transport Safety Bureau recommends that VicRoads, in conjunction with the VRCSSC and rural councils, carry out an audit of all level crossings in Victoria to ensure that they comply with the relevant sighting distance guidelines, signage and road marking standards.
Who it affects: VicRoads
Issue owner:
Operation affected:
Date, status, type
Date: 07 Feb 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR2006049
Description: RR2006049: Safety Recommendation The Australian Transport Safety Bureau recommends that the Victorian Department of Infrastructure ensure that road and rail authorities jointly assess the risks associated with B double/higher mass limit vehicles using level crossings.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 07 Feb 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR2006050
Description: RR2006050: Safety Recommendation The Australian Transport Safety Bureau recommends that the Victorian Department of Infrastructure consider measures for raising public awareness of the need to drive according to the environmental conditions and of the increased risk at passive level crossings in times of reduced visibility.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 07 Feb 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060043
Description: RR20060043: Safety Recommendation The ATSB recommends that the Victorian Department of Infrastructure, through the Victorian Railway Crossing Safety Steering Committee, re-examine the Edith Street level crossing, including the use of the ALCAM, to determine whether an upgrade of this site is warranted.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060044
Description: RR20060044: Safety Recommendation The ATSB recommends that Public Transport Safety Victoria through the Victorian Railway Crossing Safety Steering Committee liaises with the ARTC and rail operators in Victoria regarding opportunities to formulate community education/awareness programs regarding level crossing safety and risk15. 15. It is further recommended that the PTSV liaise with members of the 'Rail Safety Regulators Panel' ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060045
Description: RR20060045: Safety Recommendation The ATSB recommends that the Australian Rail Track Corporation improve communication with the Horsham Rural City Council in relation to the inspection and maintenance of level crossings, including the development of a formal Level Crossing Interface Agreement.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060046
Description: RR20060046: Safety Recommendation The ATSB recommends that the Horsham Rural City Council liaise with the Victorian Railway Crossing Safety Steering Committee regarding opportunities to formulate local community education/awareness programs for level crossings.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060047
Description: RR20060047: Safety Recommendation The ATSB recommends that the Horsham Rural City Council develop a program for the regular inspection of all level crossings in the shire to ensure that road markings and signage conform with Australian Standard AS1742.7:1993, Manual of Uniform Traffic Control Devices, Part 7: Railway Crossings.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060035
Description: RR20060035: Safety Recommendation The Australian Transport Safety Bureau recommends that Atlas Speciality Metals use appropriate tensile strapping to ensure load security during rail transit in accordance with the Pacific National Freight Loading Manual (or other applicable rail operator instructions).
Who it affects: Atlas Speciality Metals
Issue owner:
Operation affected:
Date, status, type
Date: 04 Oct 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060036
Description: RR20060036: Safety Recommendation The Australian Transport Safety Bureau recommends that Toll Express ensure that tensile strapping on incoming freight from customers is suitable and effective in ensuring load security during rail transit in accordance with the Pacific National Freight Loading Manual (or other applicable rail operator instructions).
Who it affects: Toll Express
Issue owner:
Operation affected:
Date, status, type
Date: 04 Oct 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060037
Description: RR20060037: Safety Recommendation The Australian Transport Safety Bureau recommends that Toll Express promulgate the minimum requirements for tensile strapping and load securing, in accordance with the rail operators' standards, and/or guidelines, to their customers.
Who it affects: Toll Express
Issue owner:
Operation affected:
Date, status, type
Date: 04 Oct 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060038
Description: RR20060038: Safety Recommendation The Australian Transport Safety Bureau recommends that Toll Express consider the use of containers or wagons which may help to reduce the potential for an out-of-gauge collision due to a load shift during rail transit.
Who it affects: Toll Express
Issue owner:
Operation affected:
Date, status, type
Date: 04 Oct 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060039
Description: RR20060039: Safety Recommendation The Australian Transport Safety Bureau recommends that Toll Express ensure that all securing equipment used such as webbing straps are fit for purpose and protected to ensure load security during rail transit.
Who it affects: Toll Express
Issue owner:
Operation affected:
Date, status, type
Date: 04 Oct 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060040
Description: RR20060040: Safety Recommendation The Australian Transport Safety Bureau recommends that Pacific National review their freight inspection procedures with a view to ensuring customers meet the minimum requirements for tensile strapping and load securing in accordance with the Pacific National Freight Loading Manual.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 04 Oct 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060041
Description: RR20060041: Safety Recommendation The Australian Transport Safety Bureau recommends that the ARTC review their standards and procedures to mitigate the risk of infringement of the design track centre clearance.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 04 Oct 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060042
Description: RR20060042: Safety Recommendation The Australian Transport Safety Bureau recommends that TransAdelaide review their standards and procedures to mitigate the risk of infringement of the design track centre clearance.
Who it affects: TransAdelaide
Issue owner:
Operation affected:
Date, status, type
Date: 04 Oct 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060034
Description: RR20060034: Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation and VicRoads review the level of short term protection provided3 at the Lismore to Skipton Road level crossing, particularly noting the limited visibility of approaching trains to motorists at or approaching this crossing. 3. The ATSB has noted that this crossing is scheduled ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 14 Jul 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060027
Description: RR20060027: Safety Recommendation The ATSB recommends that WestNet Rail develop, document and implement procedures for managing reduced track stability due to track maintenance. The procedures should give consideration to: The effect that maintenance may have on track stability, especially when conducted during periods of high ambient temperatures. The period of time that the track is likely to exhibit ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060028
Description: RR20060028: Safety Recommendation The ATSB recommends that WestNet Rail develop, document and implement procedures for monitoring and management of longitudinal rail movement on the defined interstate rail network. The procedures should give consideration to: Descending gradients and 'fixed point' locations, such as road level crossings, that may encourage rail bunching and a lowering of the rail's effective neutral ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060029
Description: RR20060029: Safety Recommendation The ATSB recommends that WestNet Rail develop, document and implement procedures whereby minor defects, identified through scheduled inspections, are assessed to determine factors that may have contributed to the defect.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060030
Description: RR20060030: Safety Recommendation The ATSB recommends that WestNet Rail ensure a full ballast profile for the defined interstate rail network, especially at locations that exhibit an increased risk of longitudinal rail movement.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060031
Description: RR20060031: Safety Recommendation The ATSB recommends that WestNet Rail review and document the procedure for managing potential risks to safe rail operations during periods of high ambient temperature, including the process of managing heat speed restrictions.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060032
Description: RR20060032: Safety Recommendation The ATSB recommends that WestNet Rail and its operational customers develop, document and implement procedures that clearly define the responsibilities of each party involved in a rail accident. The procedures should take a 'whole of incident' approach and give consideration to: The role of the accident investigation to identify factors that may have contributed to ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060033
Description: RR20060033: Safety Recommendation The ATSB recommends that the Western Australian Rail Safety Regulator: Actively monitor the actions initiated by organisations in response to this investigation. Recognise that the findings of this investigation may be relevant to other rail organisations or regulatory jurisdictions, and take the appropriate actions to ensure they are advised accordingly.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060019
Description: RR20060019: Safety Recommendation The ATSB recommends that Queensland Rail structure and enforce the training curriculum for trainee train controllers to ensure that practical experience at a train control workstation is undertaken in an appropriate manner at the intended stage of training. Consideration to be given to train controller workload factors in conjunction with the stage of trainee ...
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 13 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060020
Description: RR20060020: Safety Recommendation The ATSB recommends that Queensland Rail review verbal communication protocols to provide advice to employees on the use of unambiguous language.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 13 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060021
Description: RR20060021: Safety Recommendation The ATSB recommends that Queensland Rail ensure that appropriate blocking facilities are applied on the Acacia Ridge to Glenapp corridor to prevent conflicting movements between trains and non track-circuited track vehicles. Such measures to be progressed conjointly with the custodians of the rules and procedures that apply on the Glenapp to Casino corridor.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 13 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060022
Description: RR20060022: Safety Recommendation The ATSB recommends that Queensland Rail progress the issue of rule and procedure conformity to ensure that the rules and procedures on the Acacia Ridge to Glenapp corridor match those on the Glenapp to Casino corridor.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 13 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060023
Description: RR20060023: Safety Recommendation The ATSB recommends that Queensland Transport actively monitor the actions initiated by Queensland Rail in response to these recommendations.
Who it affects: Queensland Transport
Issue owner:
Operation affected:
Date, status, type
Date: 13 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060024
Description: RR20060024: Safety Recommendation The ATSB recommends that the Australian Rail Track Corporation ensure that appropriate blocking facilities are applied on the Glenapp to Casino corridor to prevent conflicting movements between trains and non track-circuited track vehicles. Such measures to be progressed conjointly with the custodians of the rules and procedures that apply on the Acacia Ridge to ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 13 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060025
Description: RR20060025: Safety Recommendation The ATSB recommends that the Australian Rail Track Corporation progress the issue of rule and procedure conformity to ensure that the rules and procedures on the Glenapp to Casino corridor match those on the Acacia Ridge to Glenapp corridor.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 13 Jun 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060010
Description: RR20060010: Safety Recommendation The ATSB recommends that Pacific National review their procedures for the marshalling of trains at South Dynon to ensure that: Communication protocols and phrases are clarified to ensure understanding and compliance. Terminal operator teams do not diminish their effectiveness by attending to multiple requirements. The terminal operator training program be reviewed to ensure a structured learning experience ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060011
Description: RR20060011: Safety Recommendation The ATSB recommends that the Australian Rail Track Corporation review the existing protection arrangements between signal 214U and the main line at Moonee Ponds Creek Junction, South Dynon to ensure that the intended function of catch-points 215D is adequate.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060012
Description: RR20060012: Safety Recommendation The ATSB recommends that Pacific National undertake a revision of their safety management system particular to the marshalling of trains in South Dynon yard and take into consideration the contributing factors to the 19 January 2005 occurrence.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060013
Description: RR20060013: Safety Recommendation The ATSB recommends that Pacific National consider a revision of their safety management system to incorporate the need for a supervisory structure in relation to trainees in terminal operator teams.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060014
Description: RR20060014: Safety Recommendation The ATSB recommends that Pacific National consider improvements to make sure that the rostered strength of terminal operator teams are adequately covered with contingencies for terminal operator sick leave and recreation leave or work is redesigned to provide safety assurance for smaller teams.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060015
Description: RR20060015: Safety Recommendation The ATSB recommends that the Victorian Department of Infrastructure consider the level of performance and implement improvements to the Moonee Ponds Creek Junction, South Dynon catch-points number 215D. The development of improvements should be based on the outcomes of a risk assessment and control measures may include but not be limited to the use ...
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060016
Description: RR20060016: Safety Recommendation The ATSB recommends that the Victorian Department of Infrastructure monitor Pacific National's revision of their safety management system particular to the marshalling of trains in South Dynon yard and their consideration of the contributing factors to the 19 January 2005 occurrence.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060017
Description: RR20060017: Safety Recommendation The ATSB recommends that the Victorian Department of Infrastructure monitor Pacific National's consideration of their safety management system to incorporate the need for a supervisory structure in relation to trainees in terminal operator teams.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060018
Description: RR20060018: Safety Recommendation The ATSB recommends that the Australasian Railway Association consider the development of specifications for catch-points and similar devices for inclusion to the Code of Practice for the Defined Interstate Rail Network.
Who it affects: Australasian Railway Association
Issue owner:
Operation affected:
Date, status, type
Date: 23 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: IR20060009
Description: IR20060009: Interim Recommendation IR20060009 The ATSB recommends that TransAdelaide: Review the departure procedures for Adelaide Station to ensure that Platform Coordinators provide railcar drivers with clear, unambiguous "Starting" signals, consistent with TransAdelaide's "Common General Operating Rules". Ensure that hand signals do not obscure a driver's view of line side signals.
Who it affects: TransAdelaide
Issue owner:
Operation affected:
Date, status, type
Date: 13 Apr 2006
Status:
Type: Interim Recommendation
Issue, description, who it affects
Number: RR20060001
Description: RR20060001: Safety Recommendation The ATSB recommends that SCT develop arrangements that do not require employees to ride a locomotive/wagon whilst it is being shunted, this should be done without compromising the safety of shunt movements; or if not feasible develop a restraint mechanism/workstation to protect a shunter from falling from a locomotive/wagon whilst carrying out a shunt ...
Who it affects: Specialised Container Transport
Issue owner:
Operation affected:
Date, status, type
Date: 31 Mar 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060002
Description: RR20060002: The ATSB recommends that SCT develop procedures that ensure a driver validates the position of a shunter, before starting a shunt movement and also regularly validates the wellbeing/whereabouts of a shunter whilst undertaking shunting activities.
Who it affects: Specialised Container Transport
Issue owner:
Operation affected:
Date, status, type
Date: 31 Mar 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060003
Description: RR20060003: The ATSB recommends that SCT undertake a thorough risk assessment of its shunting activities. Translate this risk assessment into a comprehensive safe working procedure and develop/provide an associated and accredited training program. Provide regular retraining of employees with respect to safety critical activities.
Who it affects: Specialised Container Transport
Issue owner:
Operation affected:
Date, status, type
Date: 31 Mar 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060004
Description: RR20060004: Safety Recommendation The ATSB recommends that SCT remind employees of their Occupational Health and Safety (OHS) responsibilities with respect to their personal safety, which includes a requirement to regularly check/replace worn personal protective equipment (PPE) such as safety boots/shoes and compliance with prescribed safety policies.
Who it affects: Specialised Container Transport
Issue owner:
Operation affected:
Date, status, type
Date: 31 Mar 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060005
Description: RR20060005: Saety Recommendation The ATSB recommends that SCT undertake/record results of regular audits of employees working practices to ensure that they are complying with documented safe working procedures and training directives.
Who it affects: Specialised Container Transport
Issue owner:
Operation affected:
Date, status, type
Date: 31 Mar 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060006
Description: RR20060006: Safety Recommendation The ATSB recommends that SCT ensure mandated medical instructions/restrictions are implemented. If the intent of a medical directive cannot be fully achieved consult with the medical practitioner to ensure any proposed alternative is effective.
Who it affects: Specialised Container Transport
Issue owner:
Operation affected:
Date, status, type
Date: 31 Mar 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060007
Description: RR20060007: The ATSB recommends that the South Australian Railway Safety Regulator actively monitor the actions initiated by SCT in response to this investigation.
Who it affects: South Australian Railway Safety Regulator
Issue owner:
Operation affected:
Date, status, type
Date: 31 Mar 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20060008
Description: RR20060008: The ATSB recommends that the South Australian Railway Safety Regulator recognise that the findings of this investigation may be relevant to other organisations, and take the appropriate actions to ensure they are advised accordingly.
Who it affects: South Australian Railway Safety Regulator
Issue owner:
Operation affected:
Date, status, type
Date: 31 Mar 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020014
Description: RR20020014: Arrange for a review of risk methodology for railway level crossing protection treatment levels on B-double approved routes, including line markings and signage.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020015
Description: RR20020015: Monitor the review of procedures for varying level crossing protection when local factors change, such as traffic flow and type, speed, and vegetation.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020016
Description: RR20020016: Monitor the review of the number of steam locomotive footplate visitors allowed.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020017
Description: RR20020017: Review all existing railway level crossing protection treatment levels on B-double approved routes, including line markings and signage.
Who it affects: VicRoads
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020018
Description: RR20020018: Develop community education programmes on the use and dangers of railway level crossings.
Who it affects: VicRoads
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020019
Description: RR20020019: Review procedures for varying level crossing protection when local factors change, such as traffic flow and type, speed, and vegetation.
Who it affects: VicRoads
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020020
Description: RR20020020: Actively involve the railway industry with level crossing safety issues.
Who it affects: VicRoads
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020021
Description: RR20020021: Review all existing railway level crossing protection treatment levels on B-double approved routes, including line markings and signage, in particular the Saleyards Road level crossing.
Who it affects: Benalla Rural City Council
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020022
Description: RR20020022: Develop community education programmes on the use and dangers of railway level crossings.
Who it affects: Benalla Rural City Council
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020023
Description: RR20020023: Review procedures for varying level crossing protection when local factors change, such as traffic flow and type, speed, and vegetation.
Who it affects: Benalla Rural City Council
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020024
Description: RR20020024: Actively involve the railway industry with level crossing safety issues.
Who it affects: Benalla Rural City Council
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020025
Description: RR20020025: Review the B-double route on the Racecourse Road, Gillies Street, and Saleyards Road level crossing.
Who it affects: Benalla Rural City Council
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020026
Description: RR20020026: Monitor the review of all existing railway level crossing protection treatment levels on B-double approved routes, including line markings and signage.
Who it affects: Freight Australia
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020027
Description: RR20020027: Review the number of footplate visitors allowed at any one time whilst the locomotive is in motion.
Who it affects: West Coast Railway
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020028
Description: RR20020028: Review the fatigue management process applied to crew rostering for special trains, particularly crews in secondary employment.
Who it affects: Rail Tram and Bus Union
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020029
Description: RR20020029: Review AS1742 part 7, with consideration to long and heavy vehicles such as B-doubles and increasing risks associated with these vehicles.
Who it affects: Standards Association of Australia
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020030
Description: RR20020030: In conjunction with relevant authorities review all existing railway level crossing protection treatment levels on B-double approved routes, including line markings and signage, in particular the Saleyards Road level crossing.
Who it affects: Victorian Level Crossing Committee
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20020031
Description: RR20020031: Pursue a more cost effective method of upgrading railway level crossings to provide active protection with no negative impact on safety.
Who it affects: Victorian Level Crossing Committee
Issue owner:
Operation affected:
Date, status, type
Date: 23 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050050
Description: RR20050050: The ATSB recommends that the Australian Rail Track Corporation consider appropriate modifications to the assessment of track infrastructure by inspection to identify deteriorated conditions such as those which led to this derailment.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 08 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050051
Description: RR20050051: The ATSB recommends that the Australian Rail Track Corporation consider appropriate modifications to the assessment of track geometry as a whole so that all geometrical parameters are taken into account to identify the potential for track that could compromise the integrity of rail safety.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 08 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050052
Description: RR20050052: The ATSB recommends that the Australian Rail Track Corporation consider the introduction of a standardised infrastructure methodology by way of the National Code of Practice to the DIRN in Victoria.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 08 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050053
Description: RR20050053: The ATSB recommends that the Australian Rail Track Corporation consider appropriate modifications to the assessment, including post analysis interpretation, of track infrastructure by AK Car data to identify successive dips, twists and crosslevels (cants) that could cause dynamic roll of railway vehicles.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 08 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050054
Description: RR20050054: The ATSB recommends that the Australian Rail Track Corporation give appropriate level of consideration to assessing AK Car data for repeated dips in one rail, or alternating between rails. This assessment should be considered together with variations in cross-level (cant).
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 08 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050055
Description: RR20050055: The ATSB recommends that the Australian Rail Track Corporation revise the emulation procedure used with the AK Car to provide a data set for comparison with standards, and consider a procedure using AK Car inertial data.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 08 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050056
Description: RR20050056: The ATSB recommends that the Australian Rail Track Corporation undertake a comparative track survey and track recording car measurement run to determine calibration, measurement, calculation and reporting errors, and how best to use AK Car data.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 08 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050057
Description: RR20050057: The ATSB recommends that the Victorian Department of Infrastructure monitor the Australian Rail Track Corporation's consideration of the introduction of a standardised infrastructure methodology by way of the establishment of the National Code of Practice to the DIRN in Victoria.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 08 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050043
Description: RR20050043: Safety recommendation The ATSB recommends that Pacific National: Review any ambiguity regarding the ACOP definition of a 'vehicle', and the application of that definition to multiple platform wagons. Review the loading and marshalling requirements, with consideration given to the intended application of the ACOP's Standard Marshalling Requirements and with consideration given to modern rail operations. Implement the relevant changes ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 02 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050044
Description: RR20050044: Safety recommendation The ATSB recommends that Pacific National enhance the functionality of the OASIS and TMS systems by incorporating the criteria for confirming a train for departure (including the loading and marshalling criteria).
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 02 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050045
Description: RR20050045: The ATSB recommends that Pacific National: Enhance the Train Consist Report provided to locomotive drivers such that each platform of a multi-platform drawbar connected wagon is presented as an individual wagon. Encourage drivers to refer to the Train Consist Report and tailor their driving technique to reflect any undesirable factors relating to the load distribution, such ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 02 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050046
Description: RR20050046: The ATSB recommends that Pacific National conduct further investigation and review into the suspension configuration of the RQZY wagon and similar wagons, with consideration to: the wagons' ability to handle discrete wheel impacts when in tare condition the wagons' ability to handle twisted track when loaded with a light weight empty container, noting that the wagon ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 02 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050047
Description: RR20050047: The ATSB recommends that the ARTC review the calculated and published speed limits for curves in areas of steep gradient, especially curves that are nontransitioned with all the cant runout entirely within the curve.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 02 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050048
Description: RR20050048: The ATSB recommends that the ARTC: Enhance the functionality of the WILD system to include automatically generated alarms when defined criteria are exceeded. For example, generating alarms when lightly loaded vehicles are detected within a heavy consist. Document and implement appropriate procedures for managing automatically generated alarms when defined criteria are exceeded.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 02 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050049
Description: RR20050049: The ATSB recommends that the South Australian Rail Safety Regulator: Actively monitor the actions initiated by organisations in response to this investigation. Recognise that the findings of this investigation may be relevant to other rail organisations or regulatory jurisdictions, and take the appropriate actions to ensure they are advised accordingly.
Who it affects: South Australian Rail Safety Regulator
Issue owner:
Operation affected:
Date, status, type
Date: 02 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050036
Description: RR20050036: The ATSB recommends that QR compile a fatigue management policy/standard to guide managers and workers in how to manage fatigue in planning and operational situations. This policy/standard should also provide guidance on how to deal with reported instances of fatigue.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050037
Description: RR20050037: The ATSB recommends that QR evaluate the installation of wayside secondary protective/prompt device/s in advance of signal FS66. Such device is to be compatible with all operators. This recommendation is made in light of the position of FS66 and the number of SPADs that have occurred at this signal.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050038
Description: RR20050038: The ATSB recommends that QR amend the emergency response procedures applicable to Fisherman Islands to ensure that initial notification of a SPAD is sent to the officer who has control of the signal in question.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050039
Description: RR20050039: The ATSB recommends that QR amend the emergency response procedures applicable to Fisherman Islands to ensure that initial notification of a SPAD is sent to the officer who has control of the signal in question.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050040
Description: RR20050040: The ATSB recommends that QR undertake training of all concerned in regard to emergency response and interface procedures between the Mayne train control centre and Fisherman Islands.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050041
Description: RR20050041: The ATSB recommends that QR examine methods of ensuring continued attendance by appropriately qualified employees at the Fisherman Islands area coordinator/station officer workstation.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050042
Description: RR20050042: The ATSB recommends that the Queensland Railway Safety Regulator actively monitor the actions initiated by QR in response to this investigation.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050032
Description: RR20050032: The ATSB recommends that QR review their SPAD investigations and related Employee Management System procedures with focus on the following: Ensuring that a system of investigation and counselling for relevant safetycritical staff exists, which adheres to strict timelines, to ensure SPAD incidents are fully dealt with in the timeliest manner. Investigation of SPADs includes examination of individual actions ...
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 21 Nov 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050033
Description: RR20050033: The ATSB recommends that QR undertake a review of practices and procedures at the Mayne Control Centre to cater for necessary short-term absences from train controller workstations.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 21 Nov 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050034
Description: RR20050034: The ATSB recommends that QR review their medical standards to ensure that safety-critical staff who are at high risk of incapacitation are subject to increased medical surveillance.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 21 Nov 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050035
Description: RR20050035: The ATSB recommends that QR introduce a scheme to ensure that operational managers can properly assess and act upon the risk posed by significant changes in the health of safety-critical staff who develop or exacerbate health problems between mandatory medical examinations.
Who it affects: Queensland Rail
Issue owner:
Operation affected:
Date, status, type
Date: 21 Nov 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050022
Description: RR20050022: The Australian Transport Safety Bureau recommends that RailCorp review and reinforce the use of blocking facilities to the greatest effect through initial and SMS employee training.
Who it affects: RailCorp (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050023
Description: RR20050023: The Australian Transport Safety Bureau recommends that RailCorp consider random audits by supervisory staff to review and reinforce the use of blocking facilities to signal operators.
Who it affects: RailCorp (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050024
Description: RR20050024: The Australian Transport Safety Bureau recommends that RailCorp consider reviewing the application of blocking facilities to provide effective protection.
Who it affects: RailCorp (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050025
Description: RR20050025: The Australian Transport Safety Bureau recommends that RailCorp review and reinforce the use of Special Proceed Authority forms to the greatest effect through initial and SMS employee training.
Who it affects: RailCorp (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050026
Description: RR20050026:The Australian Transport Safety Bureau recommends that RailCorp consider revised training practices with regard to 'live action' Special Proceed Authority training for signal operators.
Who it affects: RailCorp (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050027
Description: RR20050027: The Australian Transport Safety Bureau recommends that RailCorp review the content of the Network Rules and procedures so that the effective use of blocking facilities and SPAs are better defined.
Who it affects: RailCorp (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050028
Description: RR20050028:The Australian Transport Safety Bureau recommends that RailCorp review fatigue management principles to monitor and prevent roster-induced fatigue.
Who it affects: RailCorp (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050029
Description: RR20050029: The Australian Transport Safety Bureau recommends that RailCorp review the human interface design of signalling equipment at Hanbury Junction signal box.
Who it affects: RailCorp (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050030
Description: RR20050030: The Australian Transport Safety Bureau recommends that RailCorp review the maximum speed of trains whilst travelling in the wrong running direction without signals.
Who it affects: RailCorp (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050031
Description: RR20050031: The Australian Transport Safety Bureau recommends that the Independent Transport Safety and Reliability Regulator liaise with RailCorp on the effective implementation of these recommendations.
Who it affects: Independent Transport Safety and Reliability Regulator (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050012
Description: RR20050012: The ATSB recommends that the ARTC review their risk analysis for track standards to ensure that suitable track maintenance and monitoring standards, aligned with contemporary practices and workforce resources, are implemented on ARTC leased track in Victoria.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050013
Description: RR20050013: The ATSB recommends that the ARTC conduct an audit of crossing loops, turnouts and cripple sidings on their leased standard gauge track in Victoria with a view to ensuring this track is fit for intended purpose.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050014
Description: RR20050014: The ATSB recommends that the ARTC ensures compliance to section 4.6 of the ARTC Incident Management Plan TA44, specifically the requirements for immediate communication with other train control centres.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050015
Description: RR20050015:The ATSB recommends that the ARTC, in conjunction with other track owners and operators, examine ways of improving operational transparency between standard and broad gauge parallel corridors within Victoria.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050016
Description: RR20050016: The ATSB recommends that the Freight Australia Emergency Management Plan or the current equivalent (if updated or replaced by Pacific National), ensures that in the event of an incident or suspected incident on the broad gauge track that immediate contact is made with the ARTC train controller. This recommendation applies to rail corridors in Victoria ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050017
Description: RR20050017: The ATSB recommends that Pacific National reinforces the need for locomotive drivers not to increase the speed of their trains above the maximum permitted until the whole of the train is clear of a curve, turnout or temporary speed restriction.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050018
Description: RR20050018: The ATSB recommends that Pacific National ensure that locomotive speedometers and countdown/distance measuring devices (where fitted) are checked for accuracy in accordance with existing requirements.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050019
Description: RR20050019: The ATSB recommends that the Victorian Department of Infrastructure review their requirements for accreditation to ensure that suitable track maintenance and monitoring standards, aligned with contemporary practices and workforce resources, are implemented on ARTC leased track within Victoria.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050020
Description: RR20050020: The ATSB recommends that the Victorian Department of Infrastructure monitors the recommended ARTC audit of crossing loops, turnouts and cripple sidings.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050021
Description: RR20050021: The ATSB recommends that the Victorian Department of Infrastructure monitors the recommended examination of improvements to operational transparency between standard and broad gauge parallel rail corridors within Victoria.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected:
Date, status, type
Date: 18 Aug 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050003
Description: RR20050003: The ATSB recommends that Pacific National undertake a review and implementation of remedial action as required of workshop processes for the care and fitment of bearings to make sure that appropriate measures are in place to reduce the risk of subsequent cage related failure.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050004
Description: RR20050004: The ATSB recommends that Pacific National undertake a review and implementation of remedial action as required of the storage, transportation, and handling of bearings to make sure that appropriate measures are in place to reduce the risk of accidental damage, particularly with regard to stored RBUs fitted to wheel sets.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050005
Description: RR20050005: The ATSB recommends that Pacific National undertake a review and implement remedial action as required of the refurbishment and assembly of bearings to make sure that: a) appropriate measures are in place to reduce the risk of accidental damage to components b) reconditioned roller assemblies are appropriately inspected when installed c) bearing bore sizes are satisfactory at ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050006
Description: RR20050006: The ATSB recommends that Pacific National further develop and validate their procedure for the use of Wheel Condition Monitoring systems. The procedure should include but not be limited to the following: a) identification of limiting factors and circumstances for the withdrawal of wagons from service when a fault or number of developing fault readings has been detected b) ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050007
Description: RR20050007: The ATSB recommends that Pacific National continue their utilisation of Bearing Acoustic Monitoring systems with a view to improving the application of the information provided as soon as practicable and in line with their Major Hazard Action Plan.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050008
Description: RR20050008:The ATSB recommends that Pacific National develop and validate a procedure for the use of Bearing Acoustic Monitoring systems. The procedure should include but not be limited to the following: a) identification of limiting factors and circumstances for the withdrawal of wagons from service when a fault or number of ...
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050009
Description: RR20050009:The ATSB recommends that the South Australian Railway Safety Regulator monitor the implementation of validated procedures in Pacific National for the use of Wheel Impact Load Detection System/Wheel Condition Monitoring systems.
Who it affects: South Australian Railway Safety Regulator
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050010
Description: RR20050010: The ATSB recommends that the South Australian Railway Safety Regulator monitor the continued development towards feasible implementation of Bearing Acoustic Monitoring systems and ensure that validated procedures for its use are implemented in both Pacific National and the Australian Rail Track Corporation.
Who it affects: South Australian Railway Safety Regulator
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050011
Description: RR20050011: The ATSB recommends that the Australian Rail Track Corporation develop and validate a procedure for the use of Bearing Acoustic Monitoring systems. The procedure should include but not be limited to the following: a) identification of limiting factors and circumstances for the withdrawal of wagons from service when a fault or number of developing fault readings ...
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jun 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050001
Description: RR20050001:The ATSB recommends that the ARTC review track maintenance procedures to ensure that track geometry and stress free temperature are within the specified standards.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 09 Feb 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050002
Description: RR20050002:The ATSB recommends that the ARTC review the use of rail creep monuments to better monitor, record, and control rail creep.
Who it affects: Australian Rail Track Corporation
Issue owner:
Operation affected:
Date, status, type
Date: 09 Feb 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR200300023
Description: RR200300023: The ATSB recommends that the Department of Infrastructure review all accredited organisation's SMS provisions for the maintenance standards of wheel bearings. Particularly to the maximum bore size of bearings, the minimum journal diameter, storage life and procedures for extending effective service life of the bearing.
Who it affects: Victorian Department of Infrastructure
Issue owner:
Operation affected: