The inspection regime to identify rail fractures was ineffective for the condition of this track.
On 7 May 2021 V/Line provided evidence that the risk review was completed and safety actions have been implemented. They further advised that after an ONRSRS review in 2020 the safety actions were closed out.
V/Line has revised their Technical Maintenance Plan schedule to clarify that front of train inspections cannot be used to replace hi-rail patrols on the Tocumwal line.
Further, V/Line intends undertaking a risk review of the appropriateness of its current condition based responses for sleeper condition, as set out in the V/line standard for inspection and assessment.
The ATSB accepts that the replacement of front of train inspection with hi-rail patrols will increase the opportunity to detect fractured rail. The ATSB also considers that the proposed risk review, when completed, has the potential to result in a safety action that reduces the likelihood of a derailment following a fracture. The ATSB considers that the safety issue has been partially addressed and has issued the following safety recommendation.
The ATSB recommends that V/Line completes the risk review and implements safety actions to reduce the likelihood of derailment following a rail fracture.
On 7 May 2021 V/Line provided evidence that the risk review was completed and safety actions have been implemented. They further advised that after an ONRSR review in 2020 the safety actions were closed out.
V/Line has undertaken a risk review of the maintenance standard for sleeper condition (NIST-2709). The review includes potential safety actions or improvements such as maintenance response periods and inspection frequencies for identified condition deficiencies to reduce the risk so far as is reasonably practicable (SFAIRO).
V/Line reported that the outcomes of the risk review as of 9 October 2017 were:
The review completion timeframe is 1 November 2017. The review findings will be incorporated into a standard.
The risk review was completed and V/Line went through a closeout of the Katunga investigation response actions with ONRSR mid 2020.
