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