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