Production release of partially-embrittled MS21042L-4 nuts
Awareness of the potential for nut failure
Management of risk associated with poor adhesion
Cross divisional recognition of rail safety risks
Application of safety actions from internal investigations
Assessment and recording of rail safety risks
Awareness of rail safety occurrences in other jurisdictions affecting rail fleet type
Effective coordination of emergency communications
Post emergency debrief and findings
Occurrence notification standard and guideline
Driver’s manual explanation of effects and control of low adhesion
Emergency management exercises