Queensland Rail did not have an effective means of ensuring that, during situations such as a condition affecting the network (CAN), network control personnel were aware of the relevant weather monitoring systems that were unserviceable.
The ATSB is satisfied that the safety actions taken by Queensland Rail will reduce the risk of this safety issue.
In June 2020, in response to the draft ATSB report, Queensland Rail advised:
Post incident, the Network Control Centre was retrofitted with additional visual display monitors at a prominent location in the centre. On a day to day basis, these monitors are used to provide general information on the network; however, during conditions affecting the network (CANs), the monitors are utilised to provide up to date information on the weather, track and other infrastructure.
These monitors allow workers inside the Control Centre to easily identify issues with the network quickly and efficiently, without having to search through multiple screens and menus on smaller screens at their individual workstations before they can check different systems and alarms.
To mitigate the risk of a network control officer (NCO) being unaware of a fault due to an alarm being silenced by a different network control officer, additional controls have been implemented to ensure applicable weather management station faults and the alarms are detected.
A formal procedure has been implemented for managing Environmental Monitoring Station (EMS) alarms by the Fault Coordination Centre (FCC), with the Control Centre to be notified. Repair of EMS faults has been classified as attendance (high priority) with response occurring as soon as practically possible. The procedure requires:
• All faults to be reported to FCC and Control Centre to be notified.
• FCC to contract local coordinator with fault details.
• If local area staff are unable to attend, Telecoms Management to be notified and Townsville staff will be organised to attend.
• Control Centre to be notified if the fault cannot be repaired.
• If fault cannot be repaired, Telecoms management to be notified and details entered into the long text of work order.
The Control Centre has implemented the following additional controls:
• FCC and Regional Transit Manager to advise either party upon receipt of an alarm indicating a fault with an EMS.
• Responsible NCO to complete a vizirail report and record on handover.
• NCO must proactively monitor resources e.g. BOM sites, Cameras, RMS, RMS, EMS, Rail Traffic Crews or any other means available for the safe management of the Network.
• Rail traffic must be issued a Written Instruction (WART) to travel at “Restricted Speed” over the location of the related disabled device/s. The WART must remain in place until either the device is functioning correctly or there is no indication of any cause for warnings/alerts etc.
In addition, when a CAN event is implemented, the Control Centre now performs a check on the weather management system and if any faults are identified within the system, NCOs provide rail traffic crew with a written instruction to proceed through the impacted area at restricted speed.
Further to this, all new devices and replaced devices are now replaced with generic sensors. The generic sensors being added do not require calibration. Generic sensors do not require specialised skills and have generic spares. This reduces the likelihood of sensor failure and increase the ability to repair failed sensors on the spot.