Date:
Issue number
Safety issue title
Absence of measuring equipment
Safety Issue Description

Aurizon did not have measuring equipment available at its Stuart Yard to identify freight loads that were outside the permissible loading profile for transport via rail.

Issue Owner
Aurizon
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Emergency procedures coordination and completion
Safety Issue Description

TasRail’s processes for ensuring immediate network control actions in response to emergencies (such as runaway and authority exceedance) fundamentally relied on the experience and knowledge of network control officers and did not include the provision of procedures, tools and checklists detailed enough to support the effective management of specific types of incidents that require a time-critical response.

Issue Owner
TasRail
Transport Function
Rail: Operations control
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Notification of change regulatory requirements and guidance
Safety Issue Description

The guidance provided by the Office of the National Rail Safety Regulator about the requirement to submit a notification of change included limited detail about the extent or type of changes that necessitated a notification. In addition, with regard to ‘a safety critical element of rolling stock’, it did not provide detail with regard to the interpretation of ‘safety critical’ and the applicability to equipment that may not be inherently part of rolling stock (such as remote control equipment).

Issue Owner
Office of the National Rail Safety Regulator (ONRSR)
Transport Function
Rail: Other
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Rail
Issue number
Safety issue title
System safety assurance guidance for the Australian rail industry
Safety Issue Description

There was limited practical guidance specifically for the Australian rail industry for the application of system safety assurance processes to the development of complex and safety-critical rail systems.

Issue Owner
Rail Industry Safety and Standards Board (RISSB) and Office of the National Rail Safety Regulator (ONRSR)
Transport Function
Rail: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Processes for fault tracking and analysis
Safety Issue Description

TasRail did not have a reliable process to systematically identify, track and analyse reported faults on its remotely-controlled train or to identify their potential safety implications.

Issue Owner
TasRail
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Management of safety-related change
Safety Issue Description

Although TasRail had a detailed change management process in place, and had documented that the project to develop the third-generation remote control equipment was a significant change, the change management process had a limited capability to:

Issue Owner
TasRail
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Safety implications of remote control of trains
Safety Issue Description

Although there were no previous accidents attributable to TasRail’s use of remote control equipment (RCE) over 19 years, TasRail did not identify or fully assess the safety implications of remotely-controlled train operations, or those of TasRail’s specific implementation. These included the:

Issue Owner
TasRail
Transport Function
Rail: Rolling stock
Date issue released
Issue Status
No longer relevant
Mode of Transport
Rail
Issue number
Safety issue title
Remote control equipment commissioning process
Safety Issue Description

TasRail commissioned the manufacture of, and continued to use, redesigned safety-critical remote control equipment for operating a locomotive without systematic assurance of its safety, leading to excessive reliance on the manufacturer. This was because TasRail did not:

Issue Owner
TasRail
Transport Function
Rail: Rolling stock
Date issue released
Issue Status
No longer relevant
Mode of Transport
Rail
Issue number
Safety issue title
Remote control equipment system safety assurance
Safety Issue Description

Although Air Digital Engineering had safety as a design objective and safety elements were included in the remote control equipment, system safety assurance activities appropriate to its application were not conducted.

Issue Owner
Air Digital Engineering (ADE)
Transport Function
Rail: Rolling stock
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Remote control equipment design and integration problems
Safety Issue Description

The Air Digital Engineering generation 3 remote control equipment (RCE) had several safety-related design and integration problems, which were readily identifiable. These included:

Issue Owner
Air Digital Engineering (ADE)
Transport Function
Rail: Rolling stock
Date issue released
Issue Status
No longer relevant
Mode of Transport
Rail
Issue number
Safety issue title
Absence of runaway protection at Railton
Safety Issue Description

The TasRail cement loading facility at Railton had a downhill grade to the main line, and no devices to protect against a runaway.

Issue Owner
TasRail
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Loss of adhesion in risk register
Safety Issue Description

Loss of adhesion leading to increased stopping distance was not recognised as a risk source for any type of collision in V/Line’s risk registers.

Issue Owner
V/Line
Transport Function
Rail: Passenger - regional
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Train preparation checks of sand levels
Safety Issue Description

The processes involved in train preparation did not ensure a required minimum amount of sand in sand boxes.

Issue Owner
V/Line
Transport Function
Rail: Passenger - regional
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Rail
Issue number
Safety issue title
Maintenance of sanders
Safety Issue Description

Maintenance of the VLocity sander units did not include testing of sand discharge flow rates (or some other process) to confirm performance. Without performance checks over time, deficiencies could not be identified and addressed.

Issue Owner
V/Line
Transport Function
Rail: Passenger - regional
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Performance assessment of sanders
Safety Issue Description

There was no suitable assessment of the performance of sanders on the VLocity three-car set against defined acceptance criteria for improved braking performance in low adhesion conditions.

Issue Owner
V/Line [The ATSB advises that this finding may be relevant to others involved in defining and assessing sander performance in low adhesion conditions]
Transport Function
Rail: Passenger - regional
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Rail
Issue number
Safety issue title
The location of sanding nozzles
Safety Issue Description

The location of sanding nozzles (for braking) behind the wheels of the lead bogie was inconsistent with design practice existing at the time of the collision and was probably a recurring factor in diminished sander effectiveness on VLocity trains.

Issue Owner
V/Line
Transport Function
Rail: Passenger - regional
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Safety controls for a train arriving at Ballarat at excessive speed
Safety Issue Description

Safety controls were ineffective in mitigating against a train arriving at Ballarat Railway Station travelling at excessive speed and being unable to stop before colliding with the crossing gates closed against rail traffic.

Issue Owner
V/Line
Transport Function
Rail: Passenger - regional
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Management of late-notice roster changes
Safety Issue Description

Queensland Rail’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes.

Issue Owner
Queensland Rail
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Rail
Issue number
Safety issue title
Placement of signal aspect indicators at station platforms
Safety Issue Description

Queensland Rail's process for the installation of signal aspect indicators (SAIs) did not provide sufficient detail to ensure consistent and conspicuous placement of SAIs at station platforms. This problem, combined with an SAI’s non-salient indication when the platform departure signal displayed a stop indication, increased the risk that an SAI would not be correctly perceived by a train guard.

Issue Owner
Queensland Rail
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Rail
Issue number
Safety issue title
Risk management associated with changing allright signal procedures for the NGR
Safety Issue Description

Limitations in Queensland Rail’s application of risk management and change management processes relevant to the introduction of the new generation rollingstock (NGR) increased the risk of a start against signal SPAD (signals passed at danger).

Issue Owner
Queensland Rail
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail