Atsb transport safety report
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- Navigate this page:
- Safety issues
- Safety issues of significant risk in rail
- Risk control: Procedures
- Risk control: Technical failure management
- Other risk controls
- Organisational influence
- Local condition
RAILSafety factorsMost of the safety factors identified in rail investigations were risk controls or individual actions (Figure 24). About half of the safety factors were found to have contributed to an occurrence. Individual actions and risk controls ranked as the top two contributing factors (40 and 26 per cent respectively). Figure 24: Safety factors identified in all rail investigations 
Figure 25: Individual action safety factors identified in rail investigations Figure 25 F Figure 27: Local condition safety factors identified in rail investigations W Figure 28: Risk control safety factors identified in rail investigations  Issues with procedures were the most common form of risk control found in rail investigations (Figure 28). In terms of procedures, some examples included the Australian Rail Track Corporation (ARTC)21 Code of Practice that lacked guidelines regarding bolt-hole cracks and track series irregularities, and an operator’s ambiguous and decentralised instructions about crossing loop operations meant that crew training may have been ineffective or incomplete.
All 13 safety factors found in rail investigations at the organisational influences level involved safety management processes. Examples included manual systems of train management when interlocked/ engineered systems were not available; contractors not ensuring that street level crossings are conducted in accordance with all relevant standards; and the ARTC and the local council not having an interface coordination plan that defined each organisation’s responsibilities with respect to the maintenance of the street level crossing. 
Level Crossing Collision, Birkenhead, South Australia (RO- 2008-001) Safety issuesOf the 38 safety issues identified in rail investigations, the majority were of minor risk and 13 were of significant risk. There were no safety issues that carried a critical risk level. Safety issues of significant risk were associated with all functional areas except train control/ signalling (Figure 29). Vehicle maintenance and network operations carried more safety issues of significant risk than the rest of the functional areas. Figure 29: Safety issues by functional area in rail
Looking at just the safety issues of significant risk, procedures and safety management processes together made up 57 per cent all safety issues posing a significant risk in rail (36 and 21 per cent respectively). Risk control: ProceduresOf the 10 procedure-related safety issues, three involved civil maintenance, two involved network operations, and two involved vehicle maintenance. Half of the procedural safety issues in rail were of significant risk and these were related to the following. The ARTC Code of Practice did not address the possibility that a series of track regularity could cause an undesirable harmonic response in some rail vehicles. An operator’s system for inspection and maintenance of wheel bearings was not sufficiently robust to adequately manage the risks. The process for identifying potential rail defects was limited by the ultrasonic test vehicle operator’s ability to detect and assess the echo patterns correctly. The Pacific National Freight Loading Manual did not comprehensively consider lightly loaded or empty double stacked container vehicles or other freight vehicles that exhibit a large vertical surface area and their suitability for operation under high wind conditions. The ARTC Code of Practice at the time of the derailment did not categorise bolt-hole cracks as defects requiring action unless they exceeded 20 mm in length. Figure 30: Safety issues identified in rail investigations
A training and assessment safety issue involved the issuing of ambiguous or inadequate limits of authority which may increase the risk of a train overrunning an intended limit of authority. As a result of a level crossing collision between a train and a truck, the ATSB found that more research into the effectiveness of level crossing road traffic control and protection measures (facilities/ infrastructure safety issues) with respect to their effectiveness in influencing driver behaviour is needed. The one equipment/ machinery safety issue carrying significant risk involved warning/ detection systems. Investigations found that the heavy vehicle Intelligent Access Program could be enhanced from its current use as a monitoring program primarily aimed at vehicle route compliance to monitoring compliance over a range of safety and efficiency related parameters including vehicle speed and driver fatigue. 
Derailment of train near Golden Ridge WA (RO- 2009-003) Organisational influenceOut of the 12 safety management system processes safety issues, only three carried significant risk. The two safety issues involving vehicle operations involved the lack of consideration of lightly loaded or empty double stacked container vehicles in high wind conditions, and another involved a lack of ‘best practice’ by some road transport companies. The final safety issue with significant risk involved network operations and the investigation found that the manual system of train management used when interlocked/ engineered systems are not available was subject to human error and increase the risk of safe working irregularities or incidents. Local conditionRequired road pavement markings were not present or appropriately maintained at the time of a level crossing collision between a train and a road train23. This safety issue was considered to carry a significant safety risk. Directory: media media -> Applications to Drill media -> Unicef voices of Youth Chat Theme: Children and aids nigeria and Zimbabwe 13 October 2006 Background media -> Tsunami Terror Alert: Voices of Youth media -> Biblical Eschatology Presentation by: D. Paul Beck May 4, 2016 Ground Rules media -> Guide to completing the collection using the Omnibus system media -> The milk carton kids media -> Events Date and Location media -> The Gilded Age: The First Generation of Historians by H. Wayne Morgan University of Oklahoma, April 18, 1997 media -> Analysis of Law in the United Kingdom pertaining to Cross-Border Disaster Relief Prepared by: For the 30 June 2010 Foreword media -> Cuba fieldcourse 2010 Download 1.46 Mb. Share with your friends:
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shows that vehicle operation action was the most common individual action safety factor in rail occurrences. Issues with vehicle handling, monitoring and checking, 
ractures were the most common technical failure mechanism in rail (Figure 26). Examples of fractures included cracking on the tread of the wheel or high cycle fatigue cracking in the web of the rail. 
eather conditions and the physical environment were equally common to local condition safety factors in rail (Figure 27). Common weather conditions identified in rail investigations were rain / flood, temperature and wind. 
