Date:
Issue number
Safety issue title
Load restraint system
Safety Issue Description

Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose.

Issue Owner
Pacific National Pty Ltd
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Radial unitising straps contacting the cradle
Safety Issue Description

Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of strap breakage due to contact with the cradle.

Issue Owner
Pacific National Pty Ltd
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Rail
Issue number
Safety issue title
Rubber load mats not required in the Freight Loading Manual
Safety Issue Description

Pacific National's Freight Loading Manual, specific to the loading and unitising of jumbo coils, did not require the use of rubber load mat on cradles. Consequently, there was no requirement to consider the condition of load mat during inspection and maintenance. This allowed the continued use of cradles without load mat, which decreased their effectiveness at restraining loads.

Issue Owner
Pacific National Pty Ltd
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Alstom's validation and fault monitoring processes
Safety Issue Description

Neither Alstom’s validation processes nor fault monitoring processes were sufficient to detect the overcharging of batteries prior to the event.

Issue Owner
Alstom Australia Limited
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Maintenance records
Safety Issue Description

Inspection records for the December 2010 wheelset maintenance activity and wheel change on wheelset number 7E5S 831444 were not available. It is a requirement specified in Pacific National's Wagon Maintenance Manual that records be retained for a period of 12 years.

Issue Owner
Pacific National
Transport Function
Rail: Rolling stock
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Axle testing
Safety Issue Description

Axle testing on wheelset number 7E5S 831444 was not carried out during the two most recent wheelset maintenance events in January 2016 and November 2016. It is likely the axle crack existed at the time of these maintenance activities.

Issue Owner
Pacific National
Transport Function
Rail: Rolling stock
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Elements of the safety and environment management system not error tolerant
Safety Issue Description

Elements of the safety and environment management system are reliant on procedures being followed to manage safety risks. There is little scope for the system to recover when there has been a human error or other procedural error.

Issue Owner
PerisherBlue Pty Ltd
Transport Function
Rail: Operations control
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Rail
Issue number
Safety issue title
Positive isolation
Safety Issue Description

The system of placing protection flags on both ends of a train set does not provide a positive isolation of energy to ensure a train cannot be moved while it is being worked on.

Issue Owner
PerisherBlue Pty Ltd
Transport Function
Rail: Operations control
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Managing track access
Safety Issue Description

The Skitube system for managing access to track did not detect the conflict of the rail maintenance worker under the train at the same time the train was being shunted.

Issue Owner
PerisherBlue Pty Ltd
Transport Function
Rail: Operations control
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
No specific instructions provided
Safety Issue Description

VicTrack’s contractor, UGL Engineering Limited, did not provide signalling testers with specific instructions detailing the scope of work to be conducted at each stage of a project, but rather, only provided packaged isolation plans for the entire project. The absence of these instructions increased the risk of the works being incorrectly implemented.

Issue Owner
VicTrack
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Access to QR procedures and existence of Aurizon documents
Safety Issue Description

Aurizon did not provide drivers with ready access to Queensland Rail’s procedures for driver only operations and overhead line equipment emergencies when they were operating on the Queensland Rail network. In addition, Aurizon did not have procedures for driver only operations that applied to its own network.

Issue Owner
Aurizon
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Unusual loads responsibilities and guidance material
Safety Issue Description

Aurizon did not have an effective system in place for ensuring personnel required to check the securing of unusual loads (such as empty flat racks) prior to departure had sufficient knowledge of their responsibilities, and had ready access to relevant procedures, guidance and checklists.

Issue Owner
Aurizon
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Procedures for sharing workload in two-driver operation
Safety Issue Description

Aurizon’s procedures and guidance for two-driver operation during situations such as a condition affecting the network (CAN) did not facilitate the effective sharing of duties and teamwork to minimise the potential effects of degraded conditions on driver workload and fatigue.

Issue Owner
Aurizon
Transport Function
Rail: Freight
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Rail
Issue number
Safety issue title
Application of a controlled speed requirement by network control
Safety Issue Description

Queensland Rail did not have any restrictions on the distance or time that controlled speed could be used as a risk control for safe train operation in situations such as a condition affecting the network (CAN). The effectiveness of controlled speed has the significant potential to deteriorate over extended time periods due to its effect on driver workload, vigilance, fatigue and risk perception.

Issue Owner
Queensland Rail
Transport Function
Rail: Operations control
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Rail
Issue number
Safety issue title
Procedures for actively monitoring conditions ahead of a train
Safety Issue Description

Queensland Rail did not have procedures that required network control personnel to actively search for information about track conditions ahead of a train during situations such as a condition affecting the network (CAN), when conditions had the realistic potential to have deteriorated since the last patrol or train had run over the relevant sections.

Issue Owner
Queensland Rail
Transport Function
Rail: Operations control
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Advice of weather monitoring station serviceability
Safety Issue Description

Queensland Rail did not have an effective means of ensuring that, during situations such as a condition affecting the network (CAN), network control personnel were aware of the relevant weather monitoring systems that were unserviceable.

Issue Owner
Queensland Rail
Transport Function
Rail: Operations control
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Sydney Trains’ Control of worksite access and egress
Safety Issue Description

Sydney Trains' control of the access and egress to the project worksite did not ensure that all workers entering the worksite were identified and received an induction.

Issue Owner
Sydney Trains
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Rail
Issue number
Safety issue title
No procedure to cross-check master circuit diagram
Safety Issue Description

Queensland Rail did not have a procedure in place to cross-check a master circuit diagram with the existing configuration of the in-field equipment before using the diagram for safety critical work. This removed an opportunity to detect any error in master circuit diagrams.

Issue Owner
Queensland Rail
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Track maintenance
Safety Issue Description

There were track defects identified in the vicinity of the derailment site prior to the derailment. The maintenance of defects in this section of track was not successful in preventing the defects from re-occurring.

Issue Owner
Australian Rail Track Corporation (ARTC)
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
ARTC Track infrastructure activities
Safety Issue Description

Post-incident inspection of the derailment site identified a number of factors that increased the risk of a derailment in the refuge and main line. ARTC’s maintenance activities had identified some but not all of these factors prior to the derailment.

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail