Date:
Issue number
Safety issue title
Driver training
Safety Issue Description

The training and assessment of the driver did not ensure that he had an adequate understanding of the two-position signalling through Marshall. 

Issue Owner
V/Line
Transport Function
Rail: Passenger - regional
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Operational rules and procedures
Safety Issue Description

The Queensland Rail network rules, procedures and safety manual provided insufficient guidance to identify the magnitude of the potential hazard from a weather event, or define the response when encountering water that had previously overtopped the track and receded or was pooled against the track formation or ballast.

Issue Owner
Queensland Rail
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Hazard identification and assessment by rail traffic crew
Safety Issue Description

The Queensland Rail General Operational Safety Manual (MD-10-107) contained insufficient guidance for rail traffic crews to ensure the timely identification and management of a potential hazard (resulting from a weather event) that might affect the safe progress of the train.

Issue Owner
Queensland Rail
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Passenger Train Marker Light Standards
Safety Issue Description

The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Permissive Signalling System
Safety Issue Description

The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Low rim thickness
Safety Issue Description

Despite a number of incidents, Pacific National did not take adequate action, before the derailment, to reduce the risk of wheel defects, especially in light of previously identified contributors such as low rim thickness. 

Issue Owner
Pacific National
Transport Function
Rail: Freight
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Wheel inspection processes
Safety Issue Description

The wheel inspection processes and systems were not effective in detecting surface damage or cracks on the R4 wheel on wagon NHIH97081 prior to the wheel failure.

Issue Owner
Pacific National
Transport Function
Rail: Freight
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Train / platform clearances
Safety Issue Description

Due to the curvature of the track, a wide gap existed between the platform and train at the Heyington Railway Station. There are several stations on the Melbourne metropolitan rail network where wide gaps exist between platforms and trains due to track curvature. These gaps pose a risk to passengers.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Standards for train / platform clearances
Safety Issue Description

The existing standards stipulated minimum clearances between trains and platforms but did not consider the effect of the resulting gaps with respect to safe accessibility. 

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Inadequacy of the doors open warning device
Safety Issue Description

The train door open/close indicator on the driver’s control console was inadequate as a warning device once the traction interlock had deactivated. 

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
No longer relevant
Mode of Transport
Rail
Issue number
Safety issue title
The train could be moved with the carriage doors open
Safety Issue Description

As designed, the traction interlock automatically deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Fatigue management
Safety Issue Description

Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver. 

Issue Owner
Sydney Trains
Transport Function
Rail: Passenger - metropolitan
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Track patrols
Safety Issue Description

Track patrol processes were ineffective at detecting and remedying the wide gauge defect at the derailment location. Track patrols were overly reliant on the AK Car geometry recording vehicle to trigger maintenance action on this track geometry defect.  

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Rail head wear
Safety Issue Description

ARTC processes for managing the condition of the rail were ineffective despite repeated recording of rail head wear by the AK Car, and local knowledge of the worn rail. The rail was worn beyond the rail condemning limits specified within the network code of practice.

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Identification of defect location
Safety Issue Description

When the AK Car was operating in Manual mode, the methods used to identify the location of a defect, and assist track staff to locate the defect could be ineffective in certain scenarios. At the derailment location, there was a consistent offset of about 58 m between the recorded location of the wide-gauge defect and its actual location due to the presence of a ‘long kilometre’.

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Actions following derailment on 11 September 2013
Safety Issue Description

The ARTC response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October.

 

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Local Appendix Unit – North V3
Safety Issue Description

The ARTC Local Appendix Unit North – Volume 3 did not reflect current equipment installation arrangements for E Frame at Singleton.

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Unique indications for E Frame on Network control system screens
Safety Issue Description

The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display.

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Operations control
Date issue released
Issue number
Safety issue title
Pre-warning train driver of occupied track
Safety Issue Description

The practice of pathing a following train onto the same line occupied by a preceding train, without pre-warning the driver regarding the train ahead, presented an elevated level of risk.

Issue Owner
Australian Rail Track Corporation and SCT Logistics
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Train pathing
Safety Issue Description

The practice of pathing a following train onto a line occupied by a preceding train, when an alternate route was available and not obstructed, presented an elevated level of risk.

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