Date:
Issue number
Safety issue title
Standard for derailment risk on small-radius curves
Safety Issue Description

There was no network standard that directly dealt with increased derailment risk on small-radius curves.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Management of wide gauge defect
Safety Issue Description

Track geometry through the Rushall curve was not managed in accordance with Metro Trains Melbourne (MTM) network standards. A wide-gauge ‘A’ fault was not rectified in the field despite being closed-out on the asset management system.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Standard for angular discontinuity at mechanical joints
Safety Issue Description

The network’s track geometry standard did not include any specific requirement to limit a localised lateral angular discontinuity in rail line at a mechanical joint.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Track geometry standards
Safety Issue Description

The network’s track geometry standards were probably unsuitable for small-radius Broad-Gauge curves. A combination of track geometry irregularities had increased the probability of flange-climb at several locations on the small-radius Rushall curve.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Location of rail lubricators
Safety Issue Description

The positioning of the rail lubricators at this and several other locations on the network was not consistent with Metro Trains Melbourne (MTM) guidelines and probably reduced their effectiveness.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Rail lubricator maintenance
Safety Issue Description

The maintenance of rail lubricators had become less effective in the months leading up to the derailment. This work was being transferred from contractors to internal Metro Trains Melbourne (MTM) staff and the transition was not adequately managed.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Processes for evacuating trains
Safety Issue Description

Rules and procedures for detrainment do not consider a priority option of moving the train to a station or platform.

Issue Owner
NSW Trains; Sydney Trains
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Unclear purpose of communication
Safety Issue Description

The purpose of communication between key operational people was not always clearly stated nor understood leading to misunderstandings between people.

Issue Owner
NSW Trains; Sydney Trains
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Management of change
Safety Issue Description

Key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority.

Issue Owner
NSW Trains; Sydney Trains
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Train protection
Safety Issue Description

The crew of V938 detrained passengers onto the track near Kilbride without having arranged the required train protection with the ARTC Network Controller in accordance with the ARTC Network rules and procedures.

Issue Owner
NSW Trains
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Track maintenance personnel training and development
Safety Issue Description

There was an identified gap in the knowledge of track maintenance personnel that was probably the result of deficiencies in training and development. In addition, network standards for the assessment of track lateral stability, including creep management, provided limited information and tools for maintenance personnel.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Other track inspections
Safety Issue Description

There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Correcting rail creep for fixed points
Safety Issue Description

Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Rail creep
Safety Issue Description

Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Rail fractures
Safety Issue Description

The inspection regime to identify rail fractures was ineffective for the condition of this track.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Correcting rail creep for fixed points
Safety Issue Description

Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Timeframe for addressing identified rail creep
Safety Issue Description

The procedures for measuring, assessing, and remediating rail creep in spring did not ensure creep defects were addressed in a timely manner and prior to the onset of hot weather. A creep defect identified by the spring measurements was not corrected before the derailment.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Other track inspections
Safety Issue Description

There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Rail creep
Safety Issue Description

Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Network rule governing Distant signals
Safety Issue Description

The rule describing the required driver response to a Distant signal at Caution in a two-position signalling system did not fully reflect the signalling system design principles. 

Issue Owner
V/Line
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail