The reporter has raised a safety concern in relation to inadequate testing of the train detection device and signal aspect sequencing prior to an altered section of track being released for revenue services.
The reporter states, a section of track was altered and released for revenue service on [date] at [Location] in [State]. Neither the train detection asset nor the correspondence aspect sequence test were conducted properly prior to the section of track being commissioned.
On the [date], post-commissioning of the altered section of track, a passenger train positioned onto platform [x] at [Location] station. During positioning, the track section became occupied however did not indicate clear once the train moved beyond the track sections onto platform [x]. [Operator] maintenance analysed the fault and determined the direction of the axle counter for that section of track was inverted. Further testing and rectification work was conducted which impacted train running for approximately 30 minutes.
The reporter states, the resultant incident investigation report is lacking details, in particular the details of people conducting axle counting and function testing. The reporter queries why it took 12 months for recommendations to be signed off and the incident to be closed out.
The reporter is especially concerned about the safety of passengers travelling on the rail network when sections of track have had inadequate testing following maintenance or alterations.
The reporter acknowledges that [Operator] acted quickly to rectify the issue and the axle counter is now functioning in the correct configuration. However, the reporter would like assurances from [Operator] that this incident has been adequately reviewed, and that procedures will be implemented to ensure that post-track work testing is conducted adequately in the future.
The reporter queries why it took 12 months for recommendations to be signed off and the incident to be closed out.
The incident was raised and closed out in the [Contractor] incident management system on [date] which included a signed off investigation report with actions completed.
[Contractor group] undertook these works within the [Project]. [Contractor] is the principal contractor therefore the project team used their format of investigation.
[Operator] subject matter experts (SMEs) reviewed and approved this investigation before the report was signed off, concluding that there was no potential for wrong-side failure, but test procedures needed improvement.
This event was entered in the [Operator] [incident reporting system] on [date] and was left unmoderated in [incident reporting system]. [Operator] [Division] was unaware of the event and as such failed to moderate the incident.
The event remained at this stage in the workflow for 10 months when it was identified by [Operator] [Division] admin through governance processes and actioned/closed as per [Operator] requirements.
The reporter would like assurances from [Operator] that this incident has been adequately reviewed.
The reporter states the resultant incident investigation report is lacking details in particular the details of people conducting axle counting and function testing.
The incident was correctly classified as an [incident category] per [Operator] incident management and reporting procedure [code]. Events determined to be [incident category] do not require investigation as per [code].
The investigation level was determined to be a risk review based on the above classification. The report produced included an [incident analysis] methodology which was more than what was required as per [code].
The [incident analysis] investigation was conducted by a qualified investigator and reviewed by [Operator] [team] and engineering SMEs.
[Operator] has further reviewed the incident and investigation in light of this enquiry and previous concerns raised by an employee and concluded that the event was adequately reviewed as per [Operator]’s safety management system.
[Operator] made multiple attempts to consult with and gather feedback from the internal employee to address the employee’s concerns, but despite several attempts, they did not make time available or provide further information. Nonetheless, the employee continues to have the opportunity to contribute to process improvements if any observations are made or risks are identified.
Procedures will be implemented to ensure that post-track work testing is conducted adequately in the future.
The actions from the investigation address the project level post-track work testing documents and corresponding test procedures. These documents have been implemented on the project and were approved by [Operator] SMEs.
ONRSR confirms receiving ATSB REPCON report number RR2024-00022, regarding concerns of testing and commissions processes for an altered section of track. ONRSR has reviewed the reporter’s concerns and operator’s response. ONRSR is seeking additional information from the operator involved which will be reviewed and a determination made if further regulatory oversight is required. If so, further regulatory activities will be conducted as part of the 2024/2025 ONRSR national work program.