Rail safety issues and actions

No specific instructions provided

Issue number: RO-2019-002-SI-01
Issue owner: VicTrack
Transport function: Rail: Infrastructure
Background: Investigation Report RO-2019-002
Issue release date: 22 September 2020
Current issue status: Closed – Adequately addressed
Issue status justification:

The ATSB is satisfied that the action taken by VicTrack will reduce the risk of works being incorrectly implemented in relation to isolation plans.

Safety issue description

VicTrack’s contractor, UGL Engineering Limited, did not provide signalling testers with specific instructions detailing the scope of work to be conducted at each stage of a project, but rather, only provided packaged isolation plans for the entire project. The absence of these instructions increased the risk of the works being incorrectly implemented.

Proactive action

Action number: RO-2019-002-NSA-03
Action organisation: VicTrack
Date: 22 September 2020
Action status: Closed

VicTrack has advised that improvements have been made at the task-based level by including specific work instructions for each task associated with each isolation plan.

The original level crossing isolation plans were prepared by VicTrack’s contractor, UGL Engineering Pty Ltd (UGL), who was engaged due to the competence and expertise in signalling on the rail network.

UGL’s plans were subsequently reviewed and approved by ARTC and V/Line as the accredited Rail Infrastructure Manager, of the location where the incident occurred.

UGL provided its plans and instructions to its signalling testers who were to have the requisite ARTC accreditation, competence and expertise in signalling to perform the works on the rail network.

UGL was required to manage its signalling testers and provide the packaged isolation plans and specific instructions detailing the scope of work to be conducted at each stage of the project.

Post incident, VicTrack instructed UGL to revise the level crossing isolation plans to ensure that those plans, were identifiable to the requirements of the works for each stage of isolation, rather than a collective package for the whole project, in relation to the level crossing signal isolation works.

Revised plans were received by VicTrack, and forwarded to ARTC and V/Line for review and approval, which were considered to provide the requisite clarity and certainty as to the relevant works.

VicTrack appropriately and adequately addressed these concerns, on the day of the incident, and these actions also cleared the Prohibition Notice issued by ONRSR at the time.

Following this incident, VicTrack instructed UGL to revise the level crossing isolation plans to ensure that those plans, were identifiable to the requirements of the works for each stage of isolation, rather than a collective package for the whole project, in relation to the level crossing signal isolation works.

Revised plans were received by VicTrack, and forwarded to ARTC and V/Line for review and approval, which were considered to provide the requisite clarity and certainty as to the relevant works.

Last update 22 September 2020