ATSB recommendations closed in 2020-21
There were no aviation or marine safety recommendations closed in 2020–21.
Rail
Table 10: Rail – ATSB recommendations closed in 2020–21
Investigation | RO-2014-001: Derailment of Sydney Trains passenger train 602M near Edgecliff station, Sydney, NSW, on 15 January 2014 |
Safety issue | The lack of an appointed Officer in Charge of the incident site prior to the arrival of an Incident Rail Commander led to a fragmented response with no single employee having a recognised leadership role on site. |
Number | RO-2014-001-SR-026 |
Organisation | Sydney Trains |
Recommendation | The ATSB recommends that Sydney Trains, through a revision to its Incident Management Framework, adopts the positive appointment of an Officer in Charge for Level 2, 3 & 4 incidents once they have been reported. This requirement and the functions of an Officer in Charge must be included in the training of all operational Rail Management Centre (RMC) staff and all positions which may be required to adopt this role. |
Released | 3 December 2015 |
Final action | 17 June 2021 |
Final action | Sydney Trains accepted the recommendation and advised ATSB that a revision to its Incident Management Framework amended Part 3 to state: ‘Before the Rail Commander arrives on-site, the “Officer in Charge” (e.g. Train Driver, Station Manager, Infrastructure, Facilities or Maintenance Centre Manager) is responsible for first response activities and to be the point of contact for the Rail Management Centre (RMC). Upon arrival of the Rail Commander, the Officer in Charge hands over to the Rail Commander…’ The recommendation has been partially addressed. |
Investigation | RO-2018-004: Collision of Waratah passenger train A42 with buffer stop at Richmond Station, NSW, on 22 January 2018 |
Safety issue | The rostering of the driver in the days leading up to the incident was inconsistent with Sydney Trains' rostering principles. |
Number | RO-2018-004-SR-020 |
Organisation | Sydney Trains |
Recommendation | The ATSB recommends that Sydney Trains take safety action to ensure that existing procedures regarding adequate rest breaks between shift cycles and start time rotations are reinforced to safeguard against fatigue impairment of train crew. |
Released | 20 December 2019 |
Final action | 13 October 2020 |
Final action | Sydney Trains provided the following information about the action it has taken regarding this safety issue:
The ATSB is satisfied that the action taken by Sydney Trains addresses this safety issue. |
Investigation | RO-2018-008: Track obstruction due to loss of freight involving train 6WM2 and subsequent impact of passenger train 8615 with track obstruction, near Winton, Vic, on 30 March 2018 |
Safety issue | Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of strap breakage due to contact with the cradle. |
Number | RO-2018-008-SR-040 |
Organisation | Pacific National Pty Ltd |
Recommendation | The ATSB recommends that Pacific National address the risk presented by continuing to allow jumbo coils to be loaded in an orientation where all the radial straps are positioned within the contact zone between the coil and cradle. |
Released | 10 December 2020 |
Final action | 5 May 2021 |
Final action | Pacific National engineers briefed the ATSB on the results of further work. The briefing addressed the four items indicated in correspondence dated 30 March 2021. Pacific National also told the ATSB that all cradles, demountable and fixed, are being fitted with rubber load mat and that details of the mat and the requirement to inspect and maintain have been included in a draft (currently being reviewed for implementation) section of their Wagon Maintenance Manual. |
Investigation | RO-2018-008: Track obstruction due to loss of freight involving train 6WM2 and subsequent impact of passenger train 8615 with track obstruction, near Winton, Vic, on 30 March 2018 |
Safety issue | Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose. |
Number | RO-2018-008-SR-042 |
Organisation | Pacific National Pty Ltd |
Recommendation | The ATSB recommends that Pacific National review the load restraint system provided by the demountable cradle design to demonstrate that they sufficiently restrain jumbo coils against lateral accelerations and prevent coils from moving and falling during transit. |
Released | 10 December 2020 |
Final action | 5 May 2021 |
Final action | Pacific National engineers briefed the ATSB on the results of further work. The briefing addressed the four items indicated in correspondence dated 30 March 2021. Pacific National has indicated that it believes, based on calculations and measured data, that its jumbo coil carrying demountable cradles provide, at minimum, restraint capable of resisting about 0.75 g acceleration. This was greater than the actual accelerations measured by instrumentation during operation, at about 0.3 g typical (0.372 g maximum peak). Therefore, Pacific National stated that the level of load restraint offered by current demountable cradles demonstrates that they sufficiently restrain jumbo coils against lateral accelerations and prevent coils from moving and falling during transit. |
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https://www.transparency.gov.au/annual-reports/australian-transport-safety-bureau/reporting-year/2020-21-14