Queensland Rail did not have procedures that required network control personnel to actively search for information about track conditions ahead of a train during situations such as a condition affecting the network (CAN), when conditions had the realistic potential to have deteriorated since the last patrol or train had run over the relevant sections.
The ATSB is satisfied that the safety actions taken by Queensland Rail will reduce the risk of this safety issue.
Queensland Rail’s internal investigation report included the following recommendation (with a due date by end of August 2018) to the manager for freight operations (Townsville):
Develop and deliver training to Regional Transit Managers and Network Control Officers for Condition Affecting the Network events and the use of weather monitoring systems and proactive train monitoring.
In June 2020, in response to the draft ATSB report, Queensland Rail also advised:
Queensland Rail’s Rail Safety function conducted a risk assessment [of] safeworking rules and procedures to ensure they adequately manage the risk of a CAN.
Linked to this risk assessment, Queensland Rail undertook a complete review of “MD-18-20 Condition affecting the Network (CAN) Management Procedure”, ensuring that the documentation was clear in relation to the expectations on NCOs to proactively monitor the Network.
To address the concerns with NCOs actively searching for information about track conditions ahead of a train, a training package was developed and delivered to Regional Transit Managers and NCOs for CAN events and the use of weather monitoring systems for proactive train monitoring. Additionally, as a part of their training packages, including their Maintenance of Competency training, NCOs are now required to complete a scenario which requires them to manage a CAN event.
Queensland Rail has subsequently introduced “MD-20-53 Instruction – Regional Network Operational Status” which further supports the management of a CAN.
This instruction requires Regional Operations North and South to provide Network users with advice and warnings regarding potential impacts to the rail network and utilises a traffic light system (Green – Amber – Red) to help convey changes to network conditions.
It calls for additional controls to be implemented in the case of an increase in status rating, and importantly, these controls must be highly prescriptive in nature.
It includes examples such as heightened communication between NCOs and rail traffic crew, and frequent meetings with asset management teams to obtain local / on the ground knowledge / experience on condition changes. The instruction also clearly points to specific decision makers who act as a central point of contact during a change in status, and related controls that are to be implemented.
This new process provides a heightened level or management attention and focus to marshalling the full range of information sources generally and specifically available to QR when operations are to continue under operating parameters that may have changed due to weather or operational conditions.
Since this process has been rolled out the Regional Network Operational Status has been stepped at least 2 times from condition green for expected weather events on Kuranda Range in the period 22‑24 March 2020 and again on the North Coast Line between Cairns and Cardwell for the period 20‑25 May 2020, which escalated from condition green to amber for the line from Cairns to Ingham, then to Red for the line from Innisfail to Cardwell and then extending from Cairns to Cardwell in a 7.5 hour period on the 20th May 2020.
Changes introduced in “MD-20-53 Instruction – Regional Network Operational Status” help to ensure that network control personnel pass on relent information to impacted train crews and operators.
Rail operators, including both internal and third party, are informed of changes to the network status via an emailed form. The information in the form is highly prescriptive in nature.
When lifting the network status from either Green to Amber or Amber to Red, the control centre telephones each rail operator’s live operational areas to verbally confirm the change in status.
The communication clearly identifies the corridor that is potentially being impacted and the approximate location where there may be an increased risk. It also prescribes any additional controls required to be implemented considering the perceived increase in risk of operating during the identified event.
During recent CAN events, feedback has been received from other rail party operators that the enhanced communication process has been highly effective in managing risk and ensuring safe operations during extreme weather events.