The maintenance of rail lubricators had become less effective in the months leading up to the derailment. This work was being transferred from contractors to internal Metro Trains Melbourne (MTM) staff and the transition was not adequately managed.
The safety action taken by MTM should address the safety issue.
Metro Trains Melbourne (MTM) has reinforced adherence to its Management of Change Process through recruitment and new training. It has also implemented improved collaboration across MTM departments, including the establishment of a cross-divisional Wheel/Rail Interface Committee to monitor and address wheel-to-rail interface matters.
Additionally, MTM has updated its rail lubrication strategy based on an assessment of alternative lubrication technologies. This has resulted in the roll-out of electronic lubricators across the MTM network, with technical information and training to support the change.
