Safety issue
| Safety issue description |
Queensland Rail did not have a procedure in place to cross-check a master circuit diagram with the existing configuration of the in-field equipment before using the diagram for safety critical work. This removed an opportunity to detect any error in master circuit diagrams. |
|---|---|
| Issue number | RO-2018-020-SI-01 |
| Issue owner | Queensland Rail |
| Transport function | Rail: Passenger - metropolitan |
| Date issue released | 05/06/2020 |
| Issue status justification |
The ATSB is satisfied that the action taken by Queensland Rail will ensure that any errors with a master circuit diagram will be identified prior to the installation of new equipment. |
Safety action
| Action type | Proactive action |
|---|---|
| Action number | RO-2018-020-NSA-026 |
| Organisation | Queensland Rail |
| Action date | 05/06/2020 |
| Action description |
Safety action taken: Following the incident, the team lead electrician proposed a new procedure to check the in-field equipment wiring with the master circuit diagram during the planning process, before work commences. Queensland Rail subsequently introduced a new procedure, MD-18-366 GSS Part 13D Correlation of Signalling Records, to correlate the wiring as early as possible before installation. Part 2.2 notes: The prime causes for poor correlation between records and the physical wiring and equipment on site are: • Inadequate record control when the original works were installed; • Site equipment or wiring that has been altered without the corresponding source records being updated; • Multiple schemes at the same location that have been installed in a different order to that for which they were designed; • Works installed but never commissioned. |
| Action status | Closed |