Atsb transport Safety Report
Cross divisional recognition of rail safety risks
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- Safety issue description
- Response to safety issue by Queensland Rail
- Current status of the safety issue
- ATSB safety recommendation to Queensland Rail
Cross divisional recognition of rail safety risks
Safety issue description:Despite numerous occurrences of slip-slide events in the years leading up to the accident at Cleveland, Queensland Rail’s risk management processes did not precipitate a broad, cross-divisional, consideration of solutions to the issue including an investigation of the factors relating to poor wheel/rail adhesion.Response to safety issue by Queensland RailFollowing the collision at Cleveland, Queensland Rail implemented procedures to manage and reduce the incidence of wheel slide events. The procedures applied to rail traffic crew, network control officers, network maintenance staff, rolling stock engineers and rail safety management staff. Research conducted by two universities on wheel/rail contamination and work by the Wheel Rail Interface Working Group prepared a standard for the management of wheel slide events. This standard (Management of Rail Traffic Wheel Slide Events) applies to all Queensland Rail business groups and train operations. All instances of wheel slide on the network are reported and recorded. The new standard requires every wheel slide event greater than 6-cars (about 150 m) to be investigated including analysis of train event recorder information to determine the probable cause. ATSB comment in response: The ATSB notes that a new standard for the management of wheel slide events has been implemented with respect to recording wheel slide events, but is not yet mature at assessing, reviewing and implementing solutions associated with poor wheel/rail adhesion. The ATSB is satisfied that the action taken by Queensland Rail will adequately address the safety issue. The ATSB will monitor the progress of the safety action.
Application of safety actions from internal investigations
Safety issue description:Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in precipitating appropriate safety action to the findings and recommendations of their investigations into the Beerwah SPADs in 2009 which identified wheel/rail adhesion issues.Response to safety issue by Queensland RailQld Rail is implementing a newly developed Governance Risk and Compliance (GRC) project. The GRC project is designed to improve access and the quality of our governance, risk and compliance systems across all functional and corporate functions. The GRC will provide clear accountability of required actions including timeframes for completion. A number of existing systems will be decommissioned and consolidated under the GRC project. The GRC system houses the outcomes and remedial actions stemming from rail safety investigations which will be monitored and tracked through to completion to ensure all relevant actions are undertaken, within the prescribed timeframes. The GRC system provides a systemic risk management database with greater visibility across the organisation to ensure adequate linkages of identified corporate risks and controls to mitigate those risks. ATSB comment in response: The ATSB notes that the new Governance Risk and Compliance system is yet to be fully implemented so that findings of investigations which identify safety issues can be appropriately actioned and monitored. ATSB safety recommendation to Queensland RailAction number: RO-2013-005-SR-016 Action status: Monitor The Australian Transport Safety Bureau recommends that Queensland Rail undertake further work to address this safety issue.
Awareness of rail safety occurrences in other jurisdictions affecting rail fleet type
Safety issue description:Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in identifying safety issues pertinent to their fleet from rail safety occurrences in other jurisdictions involving poor wheel/rail adhesion.Response to safety issue by Queensland RailThe Interim Appraisal Report of the Wheel Rail Interface Working Group has identified a range of measures to better identify and subsequently mitigate risks associated with specific types of rolling stock within our fleet including learnings from other jurisdictions nationally and internationally. Queensland Rail advised that further work in relation to these learnings is to be undertaken. ATSB comment in response: The ATSB notes that Queensland Rail continues to research and where appropriate implement findings and recommendations from investigations of wheel slide events from other jurisdictions and learnings of Wheel Rail Interface Working Group. The ATSB is satisfied that the action proposed by Queensland Rail will, when completed, adequately address the safety issue. The ATSB will monitor the progress of the proposed safety action.
Current status of the safety issue:Issue status: Details of the current status of this safety issue are available at www.atsb.gov.au. 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 0.51 Mb. Share with your friends:
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