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Safety issues and actions

Issue, description, who it affects	Date, status, type
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
Issue, description, who it affects Issue: RO-2014-009-SI-04Processes for evacuating trains Number: RO-2014-009-SI-04 Description: RO-2014-009-SI-04:Rules and procedures for detrainment do not consider a priority option of moving the train to a station or platform. Who it affects: All rail operations Issue owner: NSW Trains; Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 17 Jan 2018 Status: Adequately addressed Type: Proactive Action   Proactive Action
Issue, description, who it affects Issue: RO-2014-009-SI-03Unclear purpose of communication Number: RO-2014-009-SI-03 Description: RO-2014-009-SI-03:The purpose of communication between key operational people was not always clearly stated nor understood leading to misunderstandings between people. Who it affects: All rail operations Issue owner: NSW Trains; Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 17 Jan 2018 Status: Adequately addressed Type: Proactive Action   Proactive Action
Issue, description, who it affects Issue: RO-2014-009-SI-02Management of change Number: RO-2014-009-SI-02 Description: RO-2014-009-SI-02:Key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority. Who it affects: All rail operations Issue owner: NSW Trains; Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 17 Jan 2018 Status: Adequately addressed Type: Proactive Action   Proactive Action
Issue, description, who it affects Issue: RO-2014-009-SI-01Train protection Number: RO-2014-009-SI-01 Description: RO-2014-009-SI-01:The crew of V938 detrained passengers onto the track near Kilbride without having arranged the required train protection with the ARTC Network Controller in accordance with the ARTC Network rules and procedures. Who it affects: All rail operations Issue owner: NSW Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 17 Jan 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2015-029-SI-04Track maintenance personnel training and development Number: RO-2015-029-SI-04 Description: RO-2015-029-SI-04:There was an identified gap in the knowledge of track maintenance personnel that was probably the result of deficiencies in training and development. In addition, network standards for the assessment of track lateral stability, including creep management, provided limited information and tools for maintenance personnel. Who it affects: Managers of rail networks Issue owner: V/Line Pty Ltd Operation affected: Rail: Infrastructure	Date, status, type Date: 12 Jul 2017 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2015-029-SI-03Other track inspections Number: RO-2015-029-SI-03 Description: RO-2015-029-SI-03:There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep. Who it affects: Managers of rail networks Issue owner: V/Line Pty Ltd Operation affected: Rail: Infrastructure	Date, status, type Date: 12 Jul 2017 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2015-029-SI-02Correcting rail creep for fixed points Number: RO-2015-029-SI-02 Description: RO-2015-029-SI-02:Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments. Who it affects: Managers of rail networks Issue owner: V/Line Pty Ltd Operation affected: Rail: Infrastructure	Date, status, type Date: 12 Jul 2017 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2015-029-SI-01Rail creep Number: RO-2015-029-SI-01 Description: RO-2015-029-SI-01:Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep. Who it affects: Managers of rail networks Issue owner: V/Line Pty Ltd Operation affected: Rail: Infrastructure	Date, status, type Date: 12 Jul 2017 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-007-SI-01 Rail fractures Number: RO-2016-007-SI-01 Description: RO-2016-007-SI-01 :The inspection regime to identify rail fractures was ineffective for the condition of this track. Who it affects: All operators of rail freight Issue owner: V/Line Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 30 May 2017 Status: Type: Proactive Action   Recommendation
Issue, description, who it affects Issue: RO-2015-022-SI-04 Correcting rail creep for fixed points Number: RO-2015-022-SI-04 Description: RO-2015-022-SI-04 :Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments. Who it affects: Managers of rail networks Issue owner: V/Line Pty Ltd Operation affected: Rail: Infrastructure	Date, status, type Date: 15 May 2017 Status: Adequately addressed Type: Proactive Action