Safety issue

Safety issue description

The inspection regime to identify rail fractures was ineffective for the condition of this track.
Issue number RO-2016-007-SI-01
Issue owner V/Line Pty Ltd
Transport function Rail: Freight
Issue status Closed – Adequately addressed
Date issue released 30/05/2017
Issue status justification

On 7 May 2021 V/Line provided evidence that the risk review was completed and safety actions have been implemented. They further advised that after an ONRSRS review in 2020 the safety actions were closed out. 

Safety action

Action type Proactive action
Action number RO-2016-007-SI-001
Organisation V/Line Pty Ltd
Action date 30/05/2017
Action description

V/Line has revised their Technical Maintenance Plan schedule to clarify that front of train inspections cannot be used to replace hi-rail patrols on the Tocumwal line.

Further, V/Line intends undertaking a risk review of the appropriateness of its current condition based responses for sleeper condition, as set out in the V/line standard for inspection and assessment.
ATSB response

The ATSB accepts that the replacement of front of train inspection with hi-rail patrols will increase the opportunity to detect fractured rail. The ATSB also considers that the proposed risk review, when completed, has the potential to result in a safety action that reduces the likelihood of a derailment following a fracture. The ATSB considers that the safety issue has been partially addressed and has issued the following safety recommendation.
Action status Closed

Safety action

Action type Safety recommendation
Action number RO-2016-007-SR-001
Organisation V/Line Pty Ltd
Action date 30/05/2017
Action description

The ATSB recommends that V/Line completes the risk review and implements safety actions to reduce the likelihood of derailment following a rail fracture.
ATSB response

On 7 May 2021 V/Line provided evidence that the risk review was completed and safety actions have been implemented. They further advised that after an ONRSR review in 2020 the safety actions were closed out. 
Action status Closed

Organisation response

Date received 12/10/2017
Organisation V/Line
Response status Closed
Response text

V/Line has undertaken a risk review of the maintenance standard for sleeper condition (NIST-2709). The review includes potential safety actions or improvements such as maintenance response periods and inspection frequencies for identified condition deficiencies to reduce the risk so far as is reasonably practicable (SFAIRO).

V/Line reported that the outcomes of the risk review as of 9 October 2017 were: 

  1. Junction welds were to be treated as per joints for the responses to a missing or deteriorated/ineffective sleeper. the NIST-2709 standard requires that sleepers either side of a weld are effective.
  2. Responses to track deterioration have been amended, including halting services earlier. 

The review completion timeframe is 1 November 2017. The review findings will be incorporated into a standard.

Organisation response

Date received 07/05/2021
Organisation V/Line
Response status Closed
Response text

The risk review was completed and V/Line went through a closeout of the Katunga investigation response actions with ONRSR mid 2020.