There were track defects identified in the vicinity of the derailment site prior to the derailment. The maintenance of defects in this section of track was not successful in preventing the defects from re-occurring.
The safety action addresses the issue at the location of the derailment and changes have been made to address maintenance issues on a more systemic level.
ARTC have advised that they have included the cause ‘train over speed transporting heavier axle loads than permitted’ into the strategic risk of train derailment.
ARTC have also reviewed Route Access Condition Notices 190007, 190008 and 190009. As a result, an amendment was made to the infrastructure assessment (below rail) section of procedures which added the requirement that:
‘The proposer for the change, shall assign the management responsibility for assessing the impact on track degradation and maintenance requirements under the influence of increased axle loads.’
The change was published on the ARTC homepage under Route Access Standards Amendments and the documents re-issued on 22 February 2019.
The ARTC consulted with Pacific National regarding:
Also, as part of their strategic plan, ARTC have introduced a number of changes, including:
These objectives are targeted at addressing systemic issues identified during the Narwonah derailment investigation by:
ARTC has also commenced a work program titled ‘Asset Management Improvement Program’; this work focusses on improving the functionality of ARTC’s Enterprise Asset Management System and it’s supporting business processes. One of the key components of this program is the introduction of a review meeting at the maintenance provisioning centres. Here maintenance personnel, work coordinators and asset assurance engineers discuss network issues that have been raised or rectified since the previous meeting. This will provide an additional level of assurance that the appropriate priority has been assigned to network issues awaiting repair. It will also ensure that the repair works are scheduled to take place accordingly, and provides a forum where the asset assurance engineer is able to review work documentation to ensure quality maintenance is undertaken.
ARTC has continued to invest funding in the Central and North West areas of New South Wales in activities such as steel and concrete re-sleepering and rail joint removal programs. These upgrades have improved the condition of the Central and North West track assets, as well as reducing the occurrence of such defects that contributed to this derailment.