Date Issue Released
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
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