The processes involved in train preparation did not ensure a required minimum amount of sand in sand boxes.
The ATSB is satisfied that the action taken by V/Line will reduce the risk of this safety issue.
V/Line advised that following a trial, sanding top-ups during overnight vehicle cleaning had been introduced at three locations. Work instruction OPWI-151 VLocity Daily Preparation is also under review and will include pictures and consistent definitions to show where the sand level meets requirements.
V/Line also advised that a concept design has been developed as an option for a future mid-life upgrade that includes automatic low sand detection and remote monitoring.
