Date:
Issue number
Safety issue title
Track Stability Maintenance Plan
Safety Issue Description

There was no Track Stability Management Plan in place for the section of track where the buckle developed – as was required by the ARTC’s CoP.

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

V/Line’s organisational processes for responding to and rectifying rail creep defects did not ensure that all such defects were addressed in a timely way.

Issue Owner
V/Line Pty Ltd
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Testing of turnouts MYD882 and MYD887
Safety Issue Description

The physical testing and commissioning regime for the VCA type 37 turnout did not require the use of standard gauge trains with 127 mm rimmed wheels.

Issue Owner
V/Line
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Safe transition of dual gauge turnouts (Preliminary report)
Safety Issue Description

Inherent to the design of many dual gauge turnouts, is a region of reduced wheel rim contact on the broad gauge switch blade (rail head) through the transfer area. In circumstances where the switch blade is insufficiently restrained, and where the passing train has a narrow (127 mm) wheel rim width, there is an increased risk of derailment.

Issue Owner
V/Line
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Contract approval process
Safety Issue Description

Contract documentation and specifications within the Services and Supply Umbrella Agreement were generic and did not adequately specify the intended purpose of the type 37 turnout.

Issue Owner
V/Line
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Design of turnouts – MYD882 and MYD887
Safety Issue Description

The design of the VCA type 37 mixed gauge turnouts (MYD882 and MYD887) was such that they were not suitable for use by rolling stock with a 127 mm rimmed wheel.

Issue Owner
V/Line
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Inspection of turnout MYD882 and train wheels
Safety Issue Description

V/Line’s processes for responding to the report by the driver of train ST21 did not limit or prevent the subsequent movement of train ST24 before checks had been carried out to identify and assess any potential track and/or rolling stock issue(s).

Issue Owner
V/Line
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Provisional type approval process
Safety Issue Description

The VCA type 37 turnout design and V/Line’s provisional type approval process did not fully identify the subtle design changes inherent with the VCA type 37 turnout in determining testing, commissioning and validation needs.

Issue Owner
V/Line
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Construction of level crossing at unsealed roads
Safety Issue Description

The method of constructing crossings at unsealed roads heightened the potential for corrosion and track degradation and limited the opportunity for effective visual inspection. The network standard for crossing construction did not directly address the particular challenges of unsealed roads.

Issue Owner
V/Line
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Track inspection regime
Safety Issue Description

The track inspection regime did not identify the deteriorated rail condition at the O’Tooles Road level crossing. The regime placed an over-reliance on ultrasonic testing and did not include sufficient supplementary systems for monitoring the condition of buried track at unsealed level crossings.

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

The ultrasonic testing regime was not effective in consistently identifying corrosion and wasting of the rail web at unsealed level crossings.

Issue Owner
Speno
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Assessment of the suitability of second-hand components
Safety Issue Description

GWA had no documented system in place to assess the suitability of second-hand components for re-use.

Issue Owner
Genesee Wyoming Australia (GWA)
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Increasing train speed
Safety Issue Description

After re-railing the track, permitted train speed was increased without due consideration of the effects of cyclic track irregularities on the dynamic performance of the WOE class wagon.

Issue Owner
Brookfield Rail
Transport Function
Rail: Infrastructure
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Train braking performance
Safety Issue Description

The loss of brake pipe integrity during the derailment event did not result in the train brakes automatically activating.

Issue Owner
Aurizon and Brookfield Rail
Transport Function
Rail: Rolling stock
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Driver reporting and cab ride arrangements
Safety Issue Description

The frequency of driver reporting and locomotive cab rides by track inspectors had been insufficient for identifying rough track through the derailment site.

Issue Owner
Aurizon and Brookfield Rail
Transport Function
Rail: Rolling stock
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
WOE class wagon, dynamic performance
Safety Issue Description

When travelling at speeds near 90 km/h on track having particular track irregularities, the WOE class wagons appear to be susceptible to harmonic oscillations of sufficient magnitude to produce wheel unloading, flange climb and derailment.

Issue Owner
Aurizon and Brookfield Rail
Transport Function
Rail: Rolling stock
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Infrastructure flood management
Safety Issue Description

A register for recording ‘special locations’ in accordance with the ARTC Engineering (Track & Civil) Code of Practice - Section 10 – Flooding, had not been established to manage track infrastructure prone to flood damage.

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Management of weather warnings
Safety Issue Description

The ARTC did not have a comprehensive system in place to identify and actively manage risks associated with severe weather events that were likely to affect the safety of their rail network.

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Response to flood event investigations
Safety Issue Description

The ARTC’s processes for developing and implementing changes to operational procedures as a result of incident investigation findings were ineffective at mitigating the risk of future similar incidents.

Issue Owner
Australian Rail Track Corporation
Transport Function
Rail: Operations control
Date issue released
Mode of Transport
Rail
Issue number
Safety issue title
Genesee & Wyoming Australia procedures for acceptance of dangerous freight
Safety Issue Description

Genesee & Wyoming Australia had no procedure in place to verify (either in total or by random selection) that the nature or condition of freight provided by their customers, complied with their Standard Condition of Carriage.

Issue Owner
Genesee & Wyoming Australia
Transport Function
Rail: Freight
Date issue released
Mode of Transport
Rail