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.
QR have implemented safety strategies across divisions. Queensland Rail advised that it has implemented a Discipline Head Framework. This Framework makes technical experts accountable for aspects of the Queensland Rail Safety and Environment Management System across nine specific disciplines. As part of implementing the Framework, safety bow ties have been identified and agreed to by all discipline heads. 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.
Following 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.
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.
