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Safety issues and actions
Issue, description, who it affects Date, status, type
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
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
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