River Embley’s planned maintenance system did not require routine testing of the compressor high temperature alarm/shutdown.
The manufacturer’s maintenance manual did not include a requirement for the routine testing of the compressor high temperature alarm/shutdown.
The ARTC does not have a check list available for network controllers to assist in identifying risks associated with the verbal authorisation of train movements for an integrated yard.
The post-2005 main landing gear wheel design had shown a susceptibility to fatigue cracking at the inner hub bearing bore shoulder radius.
There was no formal risk assessment process in use at the operator’s Horn Island base.
At the time of the last tyre change, crack initiation at the bearing bore shoulder radius was an emerging issue with no requirement for mandatory inspection of this area during a tyre change.
The operator’s winching procedure did not include the requirement to confirm adequate hover reference existed overhead an intended winch area prior to deploying personnel on the winch.
A design based on using a clearance point at the interface of CA74C and CA74D should not have been implemented until it was established that the clearance between the Up Main line and No.1 Platform Road at the interface of CA74C and CA74D tracks was adequate.
The South Improvement Alliance engineers did not effectively identify and record that the interface between CA74C and CA74D was the fouling point between the Up Main line and No.1 Platform Road and thus did not recognise that the rear of a train sitting on the Up Main line at this location would foul No.1 Platform Road. The design deficiency was caused by a long standing practice of not explicitly recording the clearance point on the Signal Arrangement Plan, Track Insulation Plan or in the Control Tables.
Although the Australian Rail Track Corporation was not resourced to actively participate in the design or commissioning phases of the Cootamundra re-signalling project, greater involvement by the Australian Rail Track Corporation (local knowledge of site geography and layout) during these phases may have assisted the South Improvement Alliance engineers in detecting the design error.
Where a design involves complex signalling arrangements, it may be beneficial to involve the designing engineer during the final onsite field testing phase as they have the best understanding of the interlocking principles. This places them in a strong position to identify any design omissions or deficiencies that may not have been evident during earlier phases of a project.
The documentation and quality control processes used by the South Improvement Alliance for the Cootamundra re-signalling project were not sufficiently robust, in particular, the closing out of identified design issues was inadequate.
Where a signalling design has implicit safety requirements that need to be validated onsite, field testers should be provided with comprehensive check notes and/or clearly annotated information that ensures specific testing requirements are not omitted.
As the re-signalling of Cootamundra neared completion it became necessary to undertake control table and software development concurrently to meet the targeted commissioning date. Normally control table and software development is done sequentially to ensure that all the control table logic is fully reflected in the final software and associated validation/testing processes.
