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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: RO-2017-013-SI-02Axle fatigue susceptibility Number: RO-2017-013-SI-02 Description: RO-2017-013-SI-02:The GATX 840P1 axle was susceptible to fatigue cracking due to relatively minor damage that was not reliably detected prior to failure. Who it affects: All users of 840P1 axles Issue owner: Incitec Pivot Limited Operation affected: Rail: Rolling stock	Date, status, type Date: 12 Jun 2019 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-013-SI-01Magnetic particle inspection Number: RO-2017-013-SI-01 Description: RO-2017-013-SI-01:Anomalies in the magnetic particle inspection procedures likely led to the crack not being detected. Who it affects: All workers conducting magnetic particle inspection Issue owner: Aurizon Operation affected: Rail: Rolling stock	Date, status, type Date: 12 Jun 2019 Status: Partially addressed Type: Proactive Action   Recommendation
Issue, description, who it affects Issue: RO-2016-006-SI-04Use of all available and reasonably practicable risk controls when parking trams Number: RO-2016-006-SI-04 Description: RO-2016-006-SI-04:STM did not require the application of all available and reasonably practicable risk controls when parking trams with respect to their location and handbrake application. Who it affects: Rolling Stock Operators Issue owner: Sydney Tramway Museum Operation affected: Rail: Operations control	Date, status, type Date: 17 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-006-SI-03Attending parked trams Number: RO-2016-006-SI-03 Description: RO-2016-006-SI-03:STM did not comply with its risk control in ensuring that trams were attended when parked. Who it affects: Sydney Tramway Museum Issue owner: Sydney Tramway Museum Operation affected: Rail: Operations control	Date, status, type Date: 17 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-006-SI-02 Change management process implementation for safety critical changes Number: RO-2016-006-SI-02 Description: RO-2016-006-SI-02 :STM did not follow its change management process for adopting the new hardwood chock type. Subsequently, the hardwood chock could not be applied reliably under the ‘J’ class wheel and could not restrict its movement. Who it affects: Rolling Stock Operators Issue owner: Sydney Tramway Museum Operation affected: Rail: Operations control	Date, status, type Date: 17 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-001-SI-03Maintenance response to recurring track defects in areas with a degraded formation Number: RO-2016-001-SI-03 Description: RO-2016-001-SI-03:A more stringent maintenance response than that for an isolated track geometry defect was not considered or implemented in accordance with ARTC’s COP. A more stringent maintenance response should have been implemented given the degraded formation and the track’s rapid deterioration between 12-14 January 2016, two days prior to the ... Who it affects: Rail Infrastructure Managers (RIMs) Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Infrastructure	Date, status, type Date: 25 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-001-SI-01Shear key installation Number: RO-2016-001-SI-01 Description: RO-2016-001-SI-01:The shear key was not constructed in accordance with the geotechnical engineer’s specification with respect to the following: a) It did not include a cross-drain. b) Its width was less than the specified width. Who it affects: Rail Infrastructure Managers (RIMs) Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Infrastructure	Date, status, type Date: 25 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-001-SI-02Surface drainage in areas with degraded formations Number: RO-2016-001-SI-02 Description: RO-2016-001-SI-02:The infrastructure manager did not ensure that there was adequate surface drainage. Vegetation blocking the drains and the lack of an adequate gradient as well as the location being at a sag point likely contributed to this.  Who it affects: Rail Infrastructure Managers (RIMs) Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Infrastructure	Date, status, type Date: 25 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-016-SI-01Track defect management Number: RO-2017-016-SI-01 Description: RO-2017-016-SI-01:ARTC allowed identified track twist defects to remain in track contrary to network track geometry requirements. Who it affects: Track Managers Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Freight	Date, status, type Date: 06 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-002-SI-01Train driver maintenance of competency assurance Number: RO-2018-002-SI-01 Description: RO-2018-002-SI-01:Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements. Who it affects: Queensland Rail Citytrain rail traffic drivers Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 27 Feb 2019 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-001-SI-01Loading of train Number: RO-2017-001-SI-01 Description: RO-2017-001-SI-01:The train was loaded by approximately 10 per cent more than that recorded on the consist, it is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train. Who it affects: All owners and operators of freight wagons Issue owner: Qube Logistics Operation affected: Rail: Freight	Date, status, type Date: 05 Dec 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2015-023-SI-01 Rail condition Number: RO-2015-023-SI-01 Description: RO-2015-023-SI-01 :The general condition of the rail on the west track, in the vicinity of the rail fracture, contributed to relatively frequent failures in that area. Who it affects: Users of the affected rail track Issue owner: BHP Billiton Operation affected: Rail: Freight	Date, status, type Date: 12 Oct 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-004-SI-01Preventative maintenance systems Number: RO-2016-004-SI-01 Description: RO-2016-004-SI-01:The presence of the earlier design of yoke on wagon NGKF 35898X was not detected during preventative maintenance activities. Who it affects: Pacific National Issue owner: Pacific National Operation affected: Rail: Operations control	Date, status, type Date: 04 Jun 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-002-SI-07Train radio functionality Number: RO-2016-002-SI-07 Description: RO-2016-002-SI-07:The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to override an initial lower-priority call. Who it affects: Owners and operators of passenger rail services in Victoria Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 16 May 2018 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-002-SI-06Standard for derailment risk on small-radius curves Number: RO-2016-002-SI-06 Description: RO-2016-002-SI-06:There was no network standard that directly dealt with increased derailment risk on small-radius curves. Who it affects: Owners and operators of passenger rail services in Victoria Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 16 May 2018 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-002-SI-05Management of wide gauge defect Number: RO-2016-002-SI-05 Description: RO-2016-002-SI-05:Track geometry through the Rushall curve was not managed in accordance with Metro Trains Melbourne (MTM) network standards. A wide-gauge ‘A’ fault was not rectified in the field despite being closed-out on the asset management system. Who it affects: Owners and operators of passenger rail services in Victoria Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 16 May 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-002-SI-02Standard for angular discontinuity at mechanical joints Number: RO-2016-002-SI-02 Description: RO-2016-002-SI-02:The network’s track geometry standard did not include any specific requirement to limit a localised lateral angular discontinuity in rail line at a mechanical joint. Who it affects: Owners and operators of passenger rail services in Victoria Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 16 May 2018 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-002-SI-04Track geometry standards Number: RO-2016-002-SI-04 Description: RO-2016-002-SI-04:The network’s track geometry standards were probably unsuitable for small-radius Broad-Gauge curves. A combination of track geometry irregularities had increased the probability of flange-climb at several locations on the small-radius Rushall curve. Who it affects: Owners and operators of passenger rail services in Victoria Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 16 May 2018 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-002-SI-03Location of rail lubricators Number: RO-2016-002-SI-03 Description: RO-2016-002-SI-03:The positioning of the rail lubricators at this and several other locations on the network was not consistent with Metro Trains Melbourne (MTM) guidelines and probably reduced their effectiveness. Who it affects: Rail: Passenger – metropolitan and regional Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 16 May 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-002-SI-01Rail lubricator maintenance Number: RO-2016-002-SI-01 Description: RO-2016-002-SI-01:The maintenance of rail lubricators had become less effective in the months leading up to the derailment. This work was being transferred from contractors to internal Metro Trains Melbourne (MTM) staff and the transition was not adequately managed. Who it affects: Owners and operators of passenger rail services in Victoria Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 16 May 2018 Status: Adequately addressed Type: Proactive Action