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Safety issues and actions
Issue, description, who it affects Date, status, type
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
Issue, description, who it affects
Issue: RO-2015-022-SI-03 Timeframe for addressing identified rail creep
Number: RO-2015-022-SI-03
Description: RO-2015-022-SI-03 :The procedures for measuring, assessing, and remediating rail creep in spring did not ensure creep defects were addressed in a timely manner and prior to the onset of hot weather. A creep defect identified by the spring measurements was not corrected before the derailment.
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
Issue, description, who it affects
Issue: RO-2015-022-SI-02 Other track inspections
Number: RO-2015-022-SI-02
Description: RO-2015-022-SI-02 :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: 15 May 2017
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-01 Rail creep
Number: RO-2015-022-SI-01
Description: RO-2015-022-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: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-009-SI-02 Network rule governing Distant signals
Number: RO-2015-009-SI-02
Description: RO-2015-009-SI-02 :The rule describing the required driver response to a Distant signal at Caution in a two-position signalling system did not fully reflect the signalling system design principles. 
Who it affects: Drivers operating on rail networks using this rule
Issue owner: V/Line
Operation affected: Rail: Operations control
Date, status, type
Date: 12 Dec 2016
Status: Not addressed
Type: Recommendation
  Proactive Action
Issue, description, who it affects
Issue: RO-2015-009-SI-01 Driver training
Number: RO-2015-009-SI-01
Description: RO-2015-009-SI-01 :The training and assessment of the driver did not ensure that he had an adequate understanding of the two-position signalling through Marshall. 
Who it affects: Drivers operating on the V/Line network
Issue owner: V/Line
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 12 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-028-SI-02 Operational rules and procedures
Number: RO-2015-028-SI-02
Description: RO-2015-028-SI-02 :The Queensland Rail network rules, procedures and safety manual provided insufficient guidance to identify the magnitude of the potential hazard from a weather event, or define the response when encountering water that had previously overtopped the track and receded or was pooled against the track formation or ballast.
Who it affects: All rail safety workers conducting work on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-04 Towage procedures
Number: MO-2015-002-SI-04
Description: MO-2015-002-SI-04 :Procedures for harbour tugs to meet inbound ships and for their co-ordinated movement in the Fremantle pilotage area were not clearly defined. On 28 February, inadequate co-ordination of the tugs and ineffective communication between Maersk Garonne’s pilot and the tug masters resulted in both tugs, the second one in particular, ...
Who it affects: All those responsible for navigation
Issue owner: Svitzer Australia; Fremantle Ports; Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2014-016-SI-02Passenger Train Marker Light Standards
Number: RO-2014-016-SI-02
Description: RO-2014-016-SI-02:The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.
Who it affects: Rail Operators on Melbourne Metropolitan Rail Network
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Other
Date, status, type
Date: 06 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-016-SI-01Permissive Signalling System
Number: RO-2014-016-SI-01
Description: RO-2014-016-SI-01:The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.
Who it affects: Rail Operators on Melbourne Metropolitan Rail Network
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Other
Date, status, type
Date: 06 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2015-015 SI-02Low rim thickness
Number: RO-2015-015 SI-02
Description: RO-2015-015 SI-02:Despite a number of incidents, Pacific National did not take adequate action, before the derailment, to reduce the risk of wheel defects, especially in light of previously identified contributors such as low rim thickness. 
Who it affects: All owners and operators of heavy haul freight wagons.
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 30 Jun 2016
Status:
Issue, description, who it affects
Issue: RO-2015-015 SI-01Wheel inspection processes
Number: RO-2015-015 SI-01
Description: RO-2015-015 SI-01:The wheel inspection processes and systems were not effective in detecting surface damage or cracks on the R4 wheel on wagon NHIH97081 prior to the wheel failure.
Who it affects: All owners and operators of heavy haul freight wagons
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 30 Jun 2016
Status:
Issue, description, who it affects
Issue: RO-2014-005-SI-04Train / platform clearances
Number: RO-2014-005-SI-04
Description: RO-2014-005-SI-04:Due to the curvature of the track, a wide gap existed between the platform and train at the Heyington Railway Station. There are several stations on the Melbourne metropolitan rail network where wide gaps exist between platforms and trains due to track curvature. These gaps pose a risk to passengers.
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-005-SI-03Standards for train / platform clearances
Number: RO-2014-005-SI-03
Description: RO-2014-005-SI-03:The existing standards stipulated minimum clearances between trains and platforms but did not consider the effect of the resulting gaps with respect to safe accessibility. 
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-005-SI-02Inadequacy of the doors open warning device
Number: RO-2014-005-SI-02
Description: RO-2014-005-SI-02:The train door open/close indicator on the driver’s control console was inadequate as a warning device once the traction interlock had deactivated. 
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: No longer relevant
Type: Recommendation
Issue, description, who it affects
Issue: RO-2014-005-SI-01The train could be moved with the carriage doors open
Number: RO-2014-005-SI-01
Description: RO-2014-005-SI-01:As designed, the traction interlock automatically deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2015-005-SI-01Fatigue management
Number: RO-2015-005-SI-01
Description: RO-2015-005-SI-01:Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver. 
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 29 Jan 2016
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-026-SI-01 Identification of defect location
Number: RO-2013-026-SI-01
Description: RO-2013-026-SI-01 :When the AK Car was operating in Manual mode, the methods used to identify the location of a defect, and assist track staff to locate the defect could be ineffective in certain scenarios. At the derailment location, there was a consistent offset of about 58 m between the recorded location ...
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-026-SI-02 Track patrols
Number: RO-2013-026-SI-02
Description: RO-2013-026-SI-02 :Track patrol processes were ineffective at detecting and remedying the wide gauge defect at the derailment location. Track patrols were overly reliant on the AK Car geometry recording vehicle to trigger maintenance action on this track geometry defect.  
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-026-SI-03Actions following derailment on 11 September 2013
Number: RO-2013-026-SI-03
Description: RO-2013-026-SI-03:The ARTC response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October.  
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
  Recommendation
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