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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: RO-2019-009-SI-004Management of late-notice roster changes Number: RO-2019-009-SI-004 Description: RO-2019-009-SI-004:Queensland Rail’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes. Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 29 Mar 2022 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2019-009-SI-001Placement of signal aspect indicators at station platforms Number: RO-2019-009-SI-001 Description: RO-2019-009-SI-001:Queensland Rail's process for the installation of signal aspect indicators (SAIs) did not provide sufficient detail to ensure consistent and conspicuous placement of SAIs at station platforms. This problem, combined with an SAI’s non-salient indication when the platform departure signal displayed a stop indication, increased the risk that an SAI ... Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 29 Mar 2022 Status: Closed – Partially addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-009-SI-003Risk management associated with changing allright signal procedures for the NGR Number: RO-2019-009-SI-003 Description: RO-2019-009-SI-003:Limitations in Queensland Rail’s application of risk management and change management processes relevant to the introduction of the new generation rollingstock (NGR) increased the risk of a start against signal SPAD (signals passed at danger). Specifically, multiple processes did not effectively consider the risk of station staff at suburban platforms ... Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 29 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-05 Fatigue management of train drivers Number: RO-2018-018-SI-05 Description: RO-2018-018-SI-05 :BHP's fatigue management processes required its train drivers to be rostered on 7 12-hour shifts, followed by a 24-hour break and then 7 12-hour shifts, with the roster pattern commencing at a wide variety of times of day. Such roster patterns were conducive to result in cumulative sleep restriction and ... Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-04Recovery controls – ATP/ECPB interaction Number: RO-2018-018-SI-04 Description: RO-2018-018-SI-04:The automatic train protection (ATP) and electronically controlled pneumatic braking (ECPB) systems on BHP’s trains could not interface to dump brake pipe pressure if an ECPB emergency or penalty brake application became ineffective in arresting an uncommanded train movement. Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-03Operating instructions – brake pipe emergencies and penalties Number: RO-2018-018-SI-03 Description: RO-2018-018-SI-03:Although operating instructions OI 17-11 (5 April 2017) and then OI 18-72 (3 November 2018) contained a safety-critical action (to apply the automatic brake handle to the pneumatic emergency position), BHP did not clearly communicate the importance and reasons for the safety-critical action to drivers, reducing the potential for the ... Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-02 Task design – brake pipe emergencies and penalties Number: RO-2018-018-SI-02 Description: RO-2018-018-SI-02 :The task of responding to brake pipe emergencies or penalties relied extensively on a driver’s memory, with limited processes in place to facilitate or cross-check a driver’s performance to ensure all safety-critical actions were completed. Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-01Risk assessment for a rail-mounted equipment interaction incident Number: RO-2018-018-SI-01 Description: RO-2018-018-SI-01:Although BHP’s risk assessment for a rail-mounted equipment interaction incident identified numerous causes and critical controls for such an incident, it was broad in scope and had limited focus on the causes and critical controls for a train runaway event. In addition, the risk assessment did not include the procedure ... Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
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-2020-008-SI-03Unaware of forced lead function Number: RO-2020-008-SI-03 Description: RO-2020-008-SI-03:The train crew had not been trained to use forced lead function which would likely have allowed the train crew to regain control of the locomotives Issue owner: Aurizon Operation affected: Rail: Rolling stock	Date, status, type Date: 26 Oct 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2020-008-SI-02Change of ends process is unclear Number: RO-2020-008-SI-02 Description: RO-2020-008-SI-02:Aurizon did not ensure train crews had a consistent understanding of how to safely change ends on banking locomotives Issue owner: Aurizon Operation affected: Rail: Rolling stock	Date, status, type Date: 26 Oct 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2020-008-SI-01The park brakes were ineffective Number: RO-2020-008-SI-01 Description: RO-2020-008-SI-01:The park brakes were ineffective in holding the locomotives on the grade in Ardglen Yard Issue owner: Aurizon Operation affected: Rail: Rolling stock	Date, status, type Date: 26 Oct 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