Rail safety issues and actions

No procedure to cross-check master circuit diagram

Issue number: RO-2018-020-SI-01
Who it affects: Rail metropolitan passenger
Issue owner: Queensland Rail
Transport function: Rail: Passenger - metropolitan
Background: Investigation Report RO-2018-020
Issue release date: 05 June 2020
Current issue status: Adequately addressed
Issue status justification:

The ATSB is satisfied that the action taken by Queensland Rail will ensure that any errors with a master circuit diagram will be identified prior to the installation of new equipment.

Safety issue description

Queensland Rail did not have a procedure in place to cross-check a master circuit diagram with the existing configuration of the in-field equipment before using the diagram for safety critical work. This removed an opportunity to detect any error in master circuit diagrams.

Proactive action

Action number: RO-2018-020-NSA-026
Action organisation: Queensland Rail
Date: 05 June 2020
Action status: Closed

Safety action taken: Following the incident, the team lead electrician proposed a new procedure to check the in-field equipment wiring with the master circuit diagram during the planning process, before work commences. Queensland Rail subsequently introduced a new procedure, MD-18-366 GSS Part 13D Correlation of Signalling Records, to correlate the wiring as early as possible before installation.

Part 2.2 notes:

The prime causes for poor correlation between records and the physical wiring and equipment on site are:

• Inadequate record control when the original works were installed;

• Site equipment or wiring that has been altered without the corresponding source records being updated;

• Multiple schemes at the same location that have been installed in a different order to that for which they were designed;

• Works installed but never commissioned.

Last update 05 June 2020