Safety issue

Safety issue description

The twist defect was not detected by TasRail’s inspection/monitoring systems, increasing the risk of derailment.
Issue number RO-2013-012-SI-01
Issue owner TasRail
Transport function Rail: Infrastructure
Date issue released 15/10/2013

Safety action

Action type Proactive action
Action number RO-2013-012-NSA-003
Organisation TasRail
Action date 07/08/2013
Action description

To improve the detection of track twist defects, TasRail have taken the following action:

  • Increased twist trolley inspection regime from 10 weekly to monthly for areas identified as high risk for this section of track. This coincides with the Track Geometry Car which runs 3 monthly thus when this occurs the higher level Track Geometry Car inspection replaces the twist trolly inspection.
  • Provide refresher training for Track Inspectors utilising external subject matter experts in fault identification and management.
  • Purchased and issued new track measurement equipment to ensure accuracy and consistency of measurements.
  • Conduct a review of the process for maintenance inspection management to ensure inspections performed to schedule.
ATSB response

The ATSB is satisfied that the action taken by TasRail should address this safety issue.
Action status Closed