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.
The implementation by Queensland Rail of the Wheel Rail Interface Working Group recommendations ongoing.
The ATSB recommends that Queensland Rail take action to mitigate risk to the safe operation of their trains in circumstances when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion.
The Australian Transport & Safety Bureau (ATSB) identified in its Preliminary Report that “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”. As a result, the ATSB recommended that “Queensland Rail take action to mitigate risk to the safe operation of their trains in circumstances when local environmental conditions result in contaminated rail running surfaces and reduced wheel/ rail adhesion”.
Actions taken by Queensland Rail:
As soon as Queensland Rail became aware of possible wheel rail interface issues with its 160/ 260 fleet, it immediately implemented a range of precautionary mitigation strategies and actions to provide for the safe operation of rollingstock.
These actions relate to:
The following text details actions and the current status
Testing of Rolling stock
Action - Analysing track adhesion to determine contaminant and likely sources of supply to be applied during on track testing.
Status - Initial testing was conducted in February 2013, with the ATSB and Unions present, which highlighted no braking issues with the 160/ 260 class vehicles. Further on track testing is to be conducted around June 2013. Testing of 160/ 260 class vehicles to model WSP behaviour with a view to advise on driving operations, performance of WSP at low adhesion levels and to investigation optimisations.
Action - Testing plan/s to be finalised in May/ June 2013. On track testing to be conducted around June 2013.
Status - Testing of other class vehicles to model WSP behaviour with a view to making comparisons with 160/ 260 class vehicles.
Action - Testing plan/s to be finalised in May/ June 2013.
Status - On track testing to be conducted around June 2013.
Data Analysis of Safety Occurrences of all Suburban Rolling stock
Action - Analysing safety occurrence data (including station overruns by location, station overruns by fleet type, signals passed at danger and slip or brake related safety occurrences) covering seven years from January 2007 to February 2013.
Status - Completed in February 2013.
Action - Monitoring and further analysis of data logger information after all wheel slide safety occurrences.
Status - Ongoing.
Trialing Sanders on Rolling stock
Action - Proposing trial and fitment of sanders (or equivalent) to rolling stock.
Status - Negotiating with the fleet manufacturer in regards to a business case to trial a sanding system on 160/ 260 class vehicles.
Action - Evaluating cost/ trial/ fitment of scrubbers (or equivalent) to rolling stock.
Status - Negotiating with fleet manufacturers in regards to other engineering options to increase adhesion including the trialling of scrubbers.
Development of Procedural Documentation to Return Affected Rolling stock into Service
Action - Development and independent validation of procedures
Status - Certificate issued. Completed in April 2013.
Development of Specifications Relating to Wheel Slip Lessons for New Generation Rolling stock
Action - Reviewing and amending current brake specifications.
Status - Addendum issued. Completed in April 2013.
Identifying Black Spot Locations Based on History of Wheel Slide Safety Occurrences
Action - Examining track in Black Spot Locations by track gangs during routine inspections.
Status - Completed in March 2013.
Action - Building contaminant risk identification into track gang routine inspection processes.
Status - Ongoing.
Action - Identifying and treating contaminants in Black Spot Locations.
Status - Completed in March 2013.
Action - Identifying locations with acute speed reductions.
Status - Completed in April 2013.
Action - Discussing Black Spot Locations with affected staff in the form of Toolbox Talks.
Status - Completed in March 2013.
Implementing Vegetation Control Measures To Prevent Contamination of the Rail
Action - Identifying heavily vegetated areas and species present in the area using aerial survey or other means.
Status - Ongoing.
Action - Changing current relevant business instruction to ensure a clean-up and inspection of rail is undertaken at the completion of tree clearing operations.
Status - Completed in March 2013.
Analysis of Track Contaminant
Action - Obtaining track samples from wheel slide safety occurrences locations
Status - Completed in February 2013.
Action - Testing of track samples taken from wheel slide safety occurrences locations to identify contaminant.
Status - Completed in March 2013.
Action - Determining how to replicate contaminant in a controlled situation.
Status - Completed in March 2013.
Action - Replicating contaminant and undertaking testing to rolling stock.
Status - Completed in April 2013.
Researching Track Contaminant
Action - Carrying out contaminant academic research.
Status - Liaising with Universities on literature available in regards to contaminants. Further testing of adhesion measurements to be conducted around June 2013.
The Reporting of All Wheel Slide Safety Occurrences on the 160/ 260 Class Vehicles
Action - Developing a Business Instruction on how to respond to all wheel slide safety occurrences.
Status - Completed in March 2013.
Action - Encouraging the reporting of all wheel slide safety occurrences on the 160/ 260 class vehicles.
Status - Ongoing.
Reviewing and Updating Current Training Regarding Wheel Slide
Action - Review and update related current training
Status - Completed in March 2013.
Action - Developing, piloting and launching a Guide on the braking system for 160/ 260 class vehicles for Rail Traffic Crew. This Guide is to explain how the braking system on the 160/ 260 class vehicles works and what Rail Traffic Crew are to expect during wheel slide situations.
Status - Completed in March 2013.
Providing Specialised Training for 160/ 260 Class Vehicles Unique Characteristics
Action - Reviewing of processes and adapting training material.
Status - Completed in April 2013.
Action - Ensuring Appropriate Training Around Fleet Specific Hazards and Fleet Characteristics and Defensive Driving Techniques
Status - Completed in March 2013. A training course, video and Special Operational Instructions were developed. The specialised training is now integrated in all new Drivers training. Two new driver schools are currently being undertaken. It is expected that all CityTrain Divers will attend and complete this course around June 2013.
Queensland 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.
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.
