Date:
Issue number
Safety issue title
QR’s track monitoring and inspection processes
Safety Issue Description

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.

Issue Owner
Queensland Rail
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Axle fatigue susceptibility
Safety Issue Description

The GATX 840P1 axle was susceptible to fatigue cracking due to relatively minor damage that was not reliably detected prior to failure.

Issue Owner
Incitec Pivot Limited
Transport Function
Rail: Rolling stock
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Magnetic particle inspection
Safety Issue Description

Anomalies in the magnetic particle inspection procedures likely led to the crack not being detected.

Issue Owner
Aurizon
Transport Function
Rail: Rolling stock
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Inaccuracies in ALCAM survey data
Safety Issue Description

Errors remained within the ALCAM database due to the type of equipment used to measure road and rail bearings during ALCAM surveys in 2009.  

Issue Owner
VicTrack
Transport Function
Rail: Passenger - regional
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Risk assessment and deployment of available risk controls
Safety Issue Description

V/Line’s level crossing assessment processes did not result in deployment of available risk controls at many passively protected acute-angle level crossings.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Passenger - regional
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Risks at other acute-angle level crossings on network
Safety Issue Description

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 from their left.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Passenger - regional
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
V/Line and Colac Otway Shire Council interaction
Safety Issue Description

The interaction between V/Line and the Colac Otway Shire Council was ineffective at addressing identified sighting issues at the Phalps Road level crossing.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Passenger - regional
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Risk controls at Phalps Road level crossing
Safety Issue Description

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.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Passenger - regional
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Use of all available and reasonably practicable risk controls when parking trams
Safety Issue Description

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.

Issue Owner
Sydney Tramway Museum
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Attending parked trams
Safety Issue Description

STM did not comply with its risk control in ensuring that trams were attended when parked.

Issue Owner
Sydney Tramway Museum
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Change management process implementation for safety critical changes
Safety Issue Description

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.

Issue Owner
Sydney Tramway Museum
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Maintenance response to recurring track defects in areas with a degraded formation
Safety Issue Description

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 derailment

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

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.

Issue Owner
Australian Rail Track Corporation (ARTC)
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Surface drainage in areas with degraded formations
Safety Issue Description

The location did not have adequate surface drainage which likely contributed to formation degradation over time.

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

ARTC allowed identified track twist defects to remain in track contrary to network track geometry requirements.

Issue Owner
Australian Rail Track Corporation (ARTC)
Transport Function
Rail: Freight
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Train driver maintenance of competency assurance
Safety Issue Description

Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements.

Issue Owner
Queensland Rail
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Loading of train
Safety Issue Description

The train was loaded by approximately 10 per cent more than that recorded on the consist, it is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train.

Issue Owner
Qube Logistics
Transport Function
Rail: Freight
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Rail condition
Safety Issue Description

The general condition of the rail on the west track, in the vicinity of the rail fracture, contributed to relatively frequent failures in that area.

Issue Owner
BHP Billiton
Transport Function
Rail: Freight
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Preventative maintenance systems
Safety Issue Description

The presence of the earlier design of yoke on wagon NGKF 35898X was not detected during preventative maintenance activities.

Issue Owner
Pacific National
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Train radio functionality
Safety Issue Description

The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to override an initial lower-priority call.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail