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Safety issues and actions
Issue, description, who it affects Date, status, type
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
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