The axle bearing installation process was not sufficient to ensure the tabs on the locking plate were installed correctly.
The ATSB notes that the actions taken to address the installation and maintenance of bearings should address the safety issue.
Sydney Trains issued a Special Action notice to their Fleet Maintenance Division to check all axle end cap bolts on SP-type bearing on the XPT, Xplorer and Endeavour fleet. This included 51 cars in the Endeavour and Xplorer fleet and 74 XPT cars. Following a fleet wide check of SP130 bearings three other bearings were identified with incorrect bolt or locking tab configuration.
Other actions to prevent recurrence included the development of documented process to review and retain new UGLU Certificate of Completion checklists. In response to a Sydney Trains' request, UGLU updated their procedure so that photographs of every end cap showing the lock tabs bent up against the flats of the end cap screws are submitted as part of the wheelset build documentation. There is now a requirement for a second worker to inspect the photograph and the checklist to be forwarded to internal UGLU stakeholders, Sydney Trains Manager Heavy Fleet.
ULGU also updated their end cap installation process to replace any end cap screw that, when torqued between 80 and 100 Nm, does not align with the lock tabs to allow the tabs to be bent up correctly. This process sometimes requires half a dozen end cap screws to be rejected before one aligns correctly to allow the lock tabs to be bent up.
