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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: RO-2018-019-SI-01Wiring error was not detected Number: RO-2018-019-SI-01 Description: RO-2018-019-SI-01:The wiring error was not detected by Metro Train Melbourne’s (MTM) verification program. Who it affects: Passenger rail transport operations Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 09 Oct 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-015-SI-01Process control Number: RO-2018-015-SI-01 Description: RO-2018-015-SI-01:V/Line did not have a documented detailed process for inhibiting and reinstating level crossing protection equipment. Who it affects: Rail: Passenger - regional Issue owner: V/Line Operation affected: Rail: Passenger - regional	Date, status, type Date: 08 Oct 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-009-SI-02Single source of information for Lookout Working prohibition Number: RO-2017-009-SI-02 Description: RO-2017-009-SI-02:Lookout Working (LOW) was implemented in an area deemed unsuitable for LOW on the Sydney Trains Worksite Protection Hazardous Locations Register (WPHLR). This is likely due to the WPHLR not being clearly stated as a reference with specific requirements that must be adhered to. Who it affects: All track managers Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 25 Jul 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-009-SI-01Use of warning lights Number: RO-2017-009-SI-01 Description: RO-2017-009-SI-01:Warning lights were utilised at Tempe to overcome sighting hazards and justify the use of Lookout Working (LOW). Warning lights rely on lookouts maintaining continuous observation and their use were not specifically referenced in the LOW Network Rules. Who it affects: All track managers Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 25 Jul 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-005-SI-02Management of rail stress Number: RO-2018-005-SI-02 Description: RO-2018-005-SI-02:A variety of techniques to indicate and record rail stress at specific locations are available, however, Aurizon had not used any of these techniques in some locations with elevated risk of rail stress, such as tangent track on steep grades. As a result, Aurizon could not readily determine the presence ... Who it affects: Train crew and passengers on board trains on Aurizon-owned track Issue owner: Aurizon Operation affected: Rail: Infrastructure	Date, status, type Date: 28 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-005-SI-01Use of hazard location register Number: RO-2018-005-SI-01 Description: RO-2018-005-SI-01:When planning track disturbing work, Aurizon’s normal practice was to use its Hazard Location Register as a record of past occurrences at a specific location. Aurizon did not use the Hazard Location Register as a resource to consider the situational characteristics of a location that may increase risk, such as ... Who it affects: Train crew and passengers on board trains on Aurizon-owned track Issue owner: Aurizon Operation affected: Rail: Infrastructure	Date, status, type Date: 28 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-007-SI-01 QR’s track monitoring and inspection processes Number: RO-2017-007-SI-01 Description: RO-2017-007-SI-01 :Queensland Rail’s track monitoring and inspection processes were not effective in identifying significant deterioration in the condition of level crossing ID 2309 and its approach roads to ensure the safe operating limits of the level crossing throughout its lifecycle. Who it affects: Rail Infrastructure Managers, Rail Operators and Road Authorities/Managers Issue owner: Queensland Rail Operation affected: Rail: Infrastructure	Date, status, type Date: 25 Jun 2019 Status: Adequately addressed Type: Proactive Action
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: Safety action pending Type: Proactive Action   Recommendation
Issue, description, who it affects Issue: RO-2016-009-SI-05Inaccuracies in ALCAM survey data Number: RO-2016-009-SI-05 Description: RO-2016-009-SI-05:Errors remained within the ALCAM database due to the type of equipment used to measure road and rail bearings during ALCAM surveys in 2009.   Who it affects: All owners and operators of rail transport services in Victoria Issue owner: VicTrack Operation affected: Rail: Passenger - regional	Date, status, type Date: 21 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-009-SI-04Risk assessment and deployment of available risk controls Number: RO-2016-009-SI-04 Description: RO-2016-009-SI-04:V/Line’s level crossing assessment processes did not result in deployment of available risk controls at many passively protected acute-angle level crossings. Who it affects: V/Line Pty Ltd Issue owner: V/Line Pty Ltd Operation affected: Rail: Passenger - regional	Date, status, type Date: 21 May 2019 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-009-SI-03Risks at other acute-angle level crossings on network Number: RO-2016-009-SI-03 Description: RO-2016-009-SI-03:More than 100 level crossings in the V/Line regional rail network (including 35 at the intersection of passenger lines and public roads) were non-compliant with the left-side viewing angle requirements of AS 1742.7:2016. These crossings had an acute road-to-rail angle that affected the ability of drivers to sight trains approaching ... Who it affects: V/Line Pty Ltd Issue owner: V/Line Pty Ltd Operation affected: Rail: Passenger - regional	Date, status, type Date: 21 May 2019 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-009-SI-02V/Line and Colac Otway Shire Council interaction Number: RO-2016-009-SI-02 Description: RO-2016-009-SI-02:The interaction between V/Line and the Colac Otway Shire Council was ineffective at addressing identified sighting issues at the Phalps Road level crossing. Who it affects: V/Line Pty Ltd Issue owner: V/Line Pty Ltd Operation affected: Rail: Passenger - regional	Date, status, type Date: 21 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-009-SI-01Risk controls at Phalps Road level crossing Number: RO-2016-009-SI-01 Description: RO-2016-009-SI-01:Available risk controls to manage the risk posed by known sighting deficiencies at the Phalps Road level crossing were not deployed by V/Line or the Colac Otway Shire Council. Who it affects: V/Line Pty Ltd Issue owner: V/Line Pty Ltd Operation affected: Rail: Passenger - regional	Date, status, type Date: 21 May 2019 Status: Adequately addressed Type: Proactive Action
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 considered 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 installed 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 location did not have adequate surface drainage which likely contributed to formation degradation over time. 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