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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: RO-2019-018-SI-03Inconsistencies with application of fatigue management system Number: RO-2019-018-SI-03 Description: RO-2019-018-SI-03:There were inconsistences with Sydney Trains’ application of their fatigue management system, in particular the the use of a bio-mathematical model to predict individual fatigue risk. (Safety issue) Issue owner: Sydney Trains Operation affected: Rail: Operations control	Date, status, type Date: 20 Dec 2021 Status: Closed – Adequately addressed
Issue, description, who it affects Issue: RO-2019-018-SI-02Signaller supervision Number: RO-2019-018-SI-02 Description: RO-2019-018-SI-02:Sydney Trains did not provide supervision at Granville signal box to ensure there was adequate coverage on both signalling panels. (Safety issue) Issue owner: Sydney Trains Operation affected: Rail: Operations control	Date, status, type Date: 20 Dec 2021 Status: Closed – Adequately addressed
Issue, description, who it affects Issue: RO-2019-018-SI-01The ASB rule and procedure for using an alternative route Number: RO-2019-018-SI-01 Description: RO-2019-018-SI-01:The ASB rule NWT 308 and procedure NPR 703 did not provide sufficient description for the task of using protecting signals for an alternative route. (Safety issue) Issue owner: Sydney Trains Operation affected: Rail: Operations control	Date, status, type Date: 20 Dec 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2020-006-SI-01 Unapproved practice during TWA Number: RO-2020-006-SI-01 Description: RO-2020-006-SI-01 :There was an unapproved practice occurring during Track Work Authority of asking the Outer Handsignaller to remove Railway Track Signals from the track as a train was closely approaching in order to let it run free, which placed the Outer Handsignaller at risk of being struck by the train. Issue owner: Sydney Trains Operation affected: Rail: Infrastructure	Date, status, type Date: 20 May 2021 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2018-002-SI-05Use of event recorders to monitor driver performance Number: RO-2018-002-SI-05 Description: RO-2018-002-SI-05:Prior to the signal passed at danger (SPAD) occurrence in January 2018, Queensland Rail did not routinely and systematically analyse recorded data to determine driver compliance with key operational rules that had been designed to minimise the risk of SPADs. Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 15 Apr 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-002-SI-04 Implementation of risk triggered commentary driving (RTCD) Number: RO-2018-002-SI-04 Description: RO-2018-002-SI-04 :After mandating the use of risk triggered commentary driving (in 2011) to mitigate the risk of signals passed at danger, Queensland Rail Citytrain did not provide the necessary support to its trainers, assessors and drivers to effectively maximise the potential benefits of the technique and minimise the potential limitations or ... Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 15 Apr 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-002-SI-03Design of the automatic warning system (AWS) Number: RO-2018-002-SI-03 Description: RO-2018-002-SI-03:The automatic warning system (AWS) provided the same audible alarm and visual indication to a driver on the approach to all restricted signals (that is, double yellow, yellow, flashing yellow and red aspects). The potential for habituation, and the absence of a higher priority alert when approaching a signal displaying ... Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 15 Apr 2021 Status: Closed – Partially addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-002-SI-02Oversight of the train driver maintenance of competency process Number: RO-2018-002-SI-02 Description: RO-2018-002-SI-02:Queensland Rail’s management oversight of the Citytrain driver maintenance of competency (MOC) process did not include planned assurance activities or regular and effective auditing of how the MOC assessments were being conducted, even after there were multiple indications that the process was not being conducted as designed. Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 07 Apr 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-009-SI-01 Inspection processes Number: RO-2018-009-SI-01 Description: RO-2018-009-SI-01 :Pacific National’s inspection processes did not identify key structural points for inspection on RRYY class wagons, including the susceptibility to cracking in the junction between container loading outriggers, pull rod boxed opening, and the bottom centre sill sections. This reduced the likelihood of cracks being detected. Issue owner: Pacific National Operation affected: Rail: Freight	Date, status, type Date: 23 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-003-SI-01 Management of track lateral stability Number: RO-2019-003-SI-01 Description: RO-2019-003-SI-01 :The ARTC systems for managing track lateral stability did not lead to the location being managed as a location potentially vulnerable to instability. Issue owner: Australian rail Track Corporation Operation affected: Rail: Freight	Date, status, type Date: 16 Dec 2020 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: RO-2018-008-SI-04Radial unitising straps not required in the Freight Loading Manual Number: RO-2018-008-SI-04 Description: RO-2018-008-SI-04:Pacific National's Freight Loading Manual did not require the use of radial unitising straps to prevent telescoping on jumbo coils where the thickness of the steel was greater than 2 mm. Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-008-SI-03Load restraint system Number: RO-2018-008-SI-03 Description: RO-2018-008-SI-03:Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose. Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action   Safety recommendation
Issue, description, who it affects Issue: RO-2018-008-SI-02Radial unitising straps contacting the cradle Number: RO-2018-008-SI-02 Description: RO-2018-008-SI-02:Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of ... Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Closed – Partially addressed Type: Safety recommendation
Issue, description, who it affects Issue: RO-2018-008-SI-01Rubber load mats not required in the Freight Loading Manual Number: RO-2018-008-SI-01 Description: RO-2018-008-SI-01:Pacific National's Freight Loading Manual, specific to the loading and unitising of jumbo coils, did not require the use of rubber load mat on cradles. Consequently, there was no requirement to consider the condition of load mat during inspection and maintenance. This allowed the continued use of cradles without load ... Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2020-005-SI-01 Alstom's validation and fault monitoring processes Number: RO-2020-005-SI-01 Description: RO-2020-005-SI-01 :Neither Alstom’s validation processes nor fault monitoring processes were sufficient to detect the overcharging of batteries prior to the event. Issue owner: Alstom Australia Limited Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 03 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-013-SI-02 Maintenance records Number: RO-2019-013-SI-02 Description: RO-2019-013-SI-02 :Inspection records for the December 2010 wheelset maintenance activity and wheel change on wheelset number 7E5S 831444 were not available. It is a requirement specified in Pacific National's Wagon Maintenance Manual that records be retained for a period of 12 years. Who it affects: All owners and maintainers of rolling stock Issue owner: Pacific National Operation affected: Rail: Rolling stock	Date, status, type Date: 24 Nov 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-013-SI-01 Axle testing Number: RO-2019-013-SI-01 Description: RO-2019-013-SI-01 :Axle testing on wheelset number 7E5S 831444 was not carried out during the two most recent wheelset maintenance events in January 2016 and November 2016. It is likely the axle crack existed at the time of these maintenance activities. Who it affects: All owners and maintainers of rolling stock Issue owner: Pacific National Operation affected: Rail: Rolling stock	Date, status, type Date: 24 Nov 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-014-SI-02Elements of the safety and environment management system not error tolerant Number: RO-2019-014-SI-02 Description: RO-2019-014-SI-02:Elements of the safety and environment management system are reliant on procedures being followed to manage safety risks. There is little scope for the system to recover when there has been a human error or other procedural error. Issue owner: PerisherBlue Pty Ltd Operation affected: Rail: Operations control	Date, status, type Date: 17 Nov 2020 Status: Closed – Partially addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-014-SI-03Positive isolation Number: RO-2019-014-SI-03 Description: RO-2019-014-SI-03:The system of placing protection flags on both ends of a train set does not provide a positive isolation of energy to ensure a train cannot be moved while it is being worked on. Issue owner: PerisherBlue Pty Ltd Operation affected: Rail: Operations control	Date, status, type Date: 17 Nov 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-014-SI-01Managing track access Number: RO-2019-014-SI-01 Description: RO-2019-014-SI-01:The Skitube system for managing access to track did not detect the conflict of the rail maintenance worker under the train at the same time the train was being shunted. Issue owner: PerisherBlue Pty Ltd Operation affected: Rail: Operations control	Date, status, type Date: 17 Nov 2020 Status: Closed – Adequately addressed Type: Proactive action