Current status of the safety issue: Issue status: Safety action pending Justification: At the time of this report release, the safety actions advised by Brookfield Rail and Aurizon had not yet been fully implemented. Driver reporting and cab ride arrangements Number: RO-2014-008-SI-03 Issue owner: Aurizon and Brookfield Rail Operation affected: Rail: Rolling and Infrastructure. Who it affects: All rail transport operators throughout Australia. Safety issue description: The frequency of driver reporting and locomotive cab rides by track inspectors had been insufficient for identifying rough track through the derailment site. Proactive safety action taken by: Aurizon and Brookfield Rail In response to this safety issue, Brookfield Rail and/or Aurizon have advised of the following proactive safety action: Brookfield Rail has increased the frequency of in cab train rides/track inspection to monthly. Brookfield Rail has issued a safety advice to all above rail operators highlighting the importance of reporting rough ride/track irregularities to Brookfield Rail train control. Aurizon has issued instructions (general order) to all of its drivers regarding a requirement to communicate rail/track faults, in particular rough riding track. Aurizon is reviewing the feasibility of using acceleration monitors on selected locomotives and/or wagons on the Defined Interstate Rail Network, (DIRN) between Perth and Kalgoorlie. Action number: RO-2014-008-NSA-009 ATSB comment in response: The ATSB is satisfied that the actions proposed by Aurizon and Brookfield Rail will, when implemented, adequately address this safety issue. Current status of the safety issue: Issue status: Safety action pending Justification: At the time of this report release, the safety actions advised by Brookfield Rail and Aurizon had not yet been fully implemented. Train braking performance Number: RO-2014-008-SI-04 Issue owner: Aurizon and Brookfield Rail Operation affected: Rail: Rolling stock and Infrastructure. Who it affects: All rail transport operators throughout Australia.
Sources and submissions Sources of information The sources of information during the investigation included the: Aurizon Data loggers and CCTV from locomotives AC4301 and AC4304 Brookfield Rail References ARA Glossary for the National Codes of Practice and Dictionary of Railway Terminology Bureau of Meteorology - Weather Observations for Kalgoorlie-Boulder (14 May 2014) RISSB Glossary of Railway Terminology – Guideline Track Stability and Buckling – Rail Stress Management, Zayne Kristian Ole (Oct 2008) Submissions Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report. A draft of this report was provided to Aurizon, Brookfield Rail, Office of the National Rail Safety Regulator, Office of Rail Safety Western Australia and the train drivers. Submissions were received from Aurizon, Brookfield Rail, Office of the National Rail Safety Regulator, Office of Rail Safety Western Australia and crew. The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.