Atsb transport Safety Report
Safety issues and actions
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- Management of risk associated with poor adhesion
- Safety issue description
- Current status of the safety issue
Safety issues and actionsThe safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices. Directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation. Queensland Rail provided a response on 1 March 2013 detailing the initiation of targeted precautionary mitigation strategies in response to the collision of train T842 at Cleveland station on 31 January 2013. On 24 May 2013, in accordance with s25A (2) of the Transport Safety Investigation Act 2003, Queensland Rail provided an update to their initial response within 90 days of the publication of the ATSB’s preliminary report and these responses are contained in the appendices of this report.
Safety issue description:Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion. Response to safety issue by Queensland RailQueensland Rail has implemented a procedure for Network maintenance staff to identify, treat and prevent rail contaminants at source. Network Control are advised when contaminants are identified and these are removed as soon as it is safe and practicable to do so. The procedure has been communicated to relevant Queensland Rail staff and a cross-divisional standard has been implemented which details the specific actions required whenever a wheel slide occurs and/or rail contaminants are identified. Queensland Rail is currently trialling a sanding system on a 3-car unit to determine whether this technology mitigates the risks of wheel slide by improving adhesion at the wheel rail interface. Stage 1 of the testing is now complete with a preliminary report due for completion in December 2013. Pending results of the trials, Queensland Rail anticipates calling tenders for the supply and fitment of a sanding system to railcars by the end of January 2014. ATSB comment in response: The ATSB notes that Queensland Rail trialling a system to mitigate the risk of reduced wheel/rail adhesion due to environmental conditions, but the solution is yet to be fully implemented. The ATSB is satisfied that the action proposed by Queensland Rail will, when complete, 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. Assessment and recording of rail safety risks
Safety issue description:Poor wheel/rail adhesion was not recognised as a risk in any of Queensland Rail’s risk registers and therefore this risk to the safety of rail operations was not being actively managed.Response to safety issue by Queensland RailQueensland Rail has implemented a Discipline Head Framework. The Discipline Head framework includes separate risk registers for each of nine specific disciplines. The development of these registers takes into account risks, causes and controls identified in current Queensland Rail risk registers. The controls identified in these registers form the Queensland Rail Safety and Environment Management System. Each discipline head is responsible for identifying discipline specific risks and controls. To ensure a cohesive approach to risk management, risk registers are shared between discipline heads to ensure that no gaps exist in the identification, assessment and control of safety risks. This process ensures that cross-discipline risks are identified, assessed and controlled. ATSB comment in response: The ATSB notes that Queensland Rail has implemented a system of discipline specific risk registers with processes to ensure cross-discipline risks are identified, assessed and controlled. However, no evidence was provided that demonstrated poor wheel/rail adhesion had been recognised as a risk under the new risk management framework. ATSB safety recommendation to Queensland Rail: Action number: RO-2013-005-SR-014 Action status: Monitor The Australian Transport Safety Bureau recommends that Queensland Rail undertake further work to ensure poor wheel/rail adhesion is recognised, assessed and controlled under the new risk management framework. 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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