RAIL SAFETY INVESTIGATION REPORT - NSW Parliament

RAIL SAFETY INVESTIGATION REPORT

WHEEL DEFECT ON FREIGHT SERVICE T401G GRETA, NSW 1 APRIL 2019

RAIL SAFETY INVESTIGATION REPORT

WHEEL DEFECT ON FREIGHT SERVICE T401G GRETA, NSW 1 APRIL 2019

Released under the provisions of Section 45C (2) of the Transport Administration Act 1988 and

Section 137 of the Passenger Transport Act 2014

Investigation Reference 04814

Cover photo: Wheel defect - Source: Comsteel

Published by: The Office of Transport Safety Investigations

Postal address: PO Box A2616, Sydney South, NSW 1235

Office location: Level 17, 201 Elizabeth Street, Sydney NSW 2000

Telephone: 02 9322 9200

Accident and incident notification: 1800 677 766

Facsimile: 02 9322 9299

E-mail: [email protected]

Internet: www.otsi.nsw.gov.au

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THE OFFICE OF TRANSPORT SAFETY INVESTIGATIONS

The Office of Transport Safety Investigations (OTSI) is an independent NSW agency whose

purpose is to improve transport safety through the investigation of incidents and accidents in

the rail, bus and ferry industries. OTSI investigations are independent of regulatory,

operator or other external entities.

Established on 1 January 2004 by the Transport Administration Act 1988 (NSW), and

confirmed by amending legislation as an independent statutory office on 1 July 2005, OTSI

is responsible for determining the contributing factors of accidents and to make

recommendations for the implementation of remedial safety action to prevent

recurrence. Importantly, however, OTSI does not confine itself to the consideration of just

those matters that contributed to a particular accident; it also seeks to identify any transport

safety matters which, if left unaddressed, might contribute to other accidents.

OTSI’s investigations are conducted under powers conferred by the Transport Administration

Act 1988, Passenger Transport Act 1990 and Passenger Transport Act 2014. Additionally,

all OTSI publications that are considered investigation reports are also conferred by this Act.

OTSI investigators normally seek to obtain information cooperatively when conducting an

accident investigation. However, where it is necessary to do so, OTSI investigators may

exercise statutory powers to interview persons, enter premises, examine, and retain physical

and documentary evidence.

It is not within OTSI’s jurisdiction, nor an object of its investigations, to apportion blame or

determine liability. At all times, OTSI’s investigation reports strive to reflect our balanced

approach to the investigation, that properly explains what happened, and why, in a fair and

unbiased manner.

Once OTSI has completed an investigation, its report is provided to the NSW Minister for

Transport and Roads for tabling in Parliament. The Minister is required to table the report in

both Houses of the NSW Parliament within seven days of receiving it. Following tabling, the

report is published on OTSI’s website at www.otsi.nsw.gov.au.

.

OTSI Rail Safety Investigation

Wheel Defect, Greta, 01 April 2019 i

CONTENTS

TABLE OF FIGURES ii

EXECUTIVE SUMMARY iii

PART 1 FACTUAL INFORMATION 1

The occurrence 1 Wheel information 3

Related incidents 4

Remedial actions 5

PART 2 ANALYSIS 7

Wheel examination 7

Wheel maintenance 14

Wheel impact load detection 15

PART 3 FINDINGS 17

Contributing Factors 17

Other Findings 17

PART 4 RECOMMENDATIONS 18

PART 6 APPENDICES 19

Appendix 1: Sources, Submissions and Acknowledgements 19

Appendix 2: Wheel information 21

Appendix 3: ONRSR Safety Bulletin 22


Wheel Defect, Greta, 01 April 2019 ii

TABLE OF FIGURES

Figure 1: Location of incident 1

Figure 2: Wagon schematic with identification of wheel positions 2

Figure 3: Cracking in wheel tread 2

Figure 4: Manufacturing records for wheel 3

Figure 5: Thermal cracks identified on wheel at Pangela NSW (2015) 5

Figure 6: Field side ridge and tread cracks on Greta wheel 7

Figure 7: Outboard side ridge and tread cracks on Greta wheel 8

Figure 8: Magnetic particle inspection on Greta wheel 9

Figure 9: Ultrasonic test markings on Greta wheel showing discontinuity depth (mm) 10

Figure 10: Chemical composition of Greta wheel 11

Figure 11: Mircostructure at initiation point exhibiting a typical pearlitic microstructure with fine grain boundary ferrite 11

Figure 12: Cross section at the initiation point. No indication of non-metallic inclusions on the crack surface. Magnification X100 12

Figure 13: Brinell markings on Greta wheel 13

Figure 14: Micro hardness reading on Greta wheel 14

Figure 15: Wheel data at re-profiling intervals and incident date on Greta wheel 14

Figure 16: Wayside monitoring equipment in the Hunter Region, NSW 16

Figure 17: Standard terminology for wheels 21

Figure 18: Measuring the rim thickness 21


Wheel Defect, Greta, 01 April 2019 iii

EXECUTIVE SUMMARY

On 1 April 2019, as Pacific National freight service T401G entered the Greta Train

Service Facility, a cracked wheel was detected by an operations supervisor. The

cracked wheel was on the 34th wagon in the consist and the crack was evident on

both sides of the wheel. The bogie was removed from the wagon and the wheel later

sent for metallurgical examination. There was no injury or damage as a result of the

cracked wheel.

A metallurgical analysis found that the cracking in the wheel had likely propagated

from subsurface rolling contact fatigue. The rim cracking had multiple fatigue

initiation sites located at different depths from the wheel tread. Seven fatigue crack

initiation sites were detected. The wheel was manufactured in 2006 and had

travelled approximately 1,170,000 km up until the time of the incident.

The investigation found that maintenance processes were ineffective in allowing this

wheel to return to service with an identified defect after undergoing wheel shop

maintenance in 2016.

A number of recommendations to Pacific National were made, including:

Evaluate the existing processes for communication between Pacific National

and maintenance contractors to ensure that the reasons for wheelset

removal are accurately conveyed.

Review the non-destructive testing requirements for wheels in the Pacific

National Wagon Maintenance Manual and ensure the requirements are clear

to maintenance contractors.

Conduct regular audits on wheelset maintenance practices, including non-

destructive testing processes, to ensure compliance with Pacific National

specifications.

Full details of the Findings and Recommendations of this investigation are contained

in Parts 3 and 4 respectively.


Wheel Defect, Greta, 01 April 2019 1

PART 1 FACTUAL INFORMATION

The occurrence

1.1 At 13301 on 1 April 2019, Pacific National freight service T401G entered the

Greta Train Service Facility (see Figure 1) as part of its regular 28-day

examination. The train was crewed by a driver and a second person. An

operations supervisor, who was walking next to the moving train, noticed a

noise coming from one of the wheels.

Source: Geoscience Australia, annotated by OTSI

Figure 1: Location of incident

1.2 An inspection of the train T401G identified a cracked wheel on the 34th

wagon (NHRH50260T).2 The cracked wheel was from wheelset 1G6S9862 in

the L4 position (see Figure 2). The incident was reported to Office of National

Rail Safety Regulator (ONRSR) on 3 April 2019.

1 Times in this report are in 24-hour clock form in Australian Eastern Standard Time. 2 The wheel type was RLN4.5-212, Heat number: C37043, Grade: AAR M107 Class BM, Batch: WDZ, Serial No. 06021468, Dispatch Date: 24 October 2006.



Source: OTSI

Figure 2: Wagon schematic with identification of wheel positions

1.3 The rear bogie was removed from the wagon and the bogie was examined by

Pacific National’s engineering maintenance personnel before the L4 wheelset

was removed and prepared for a metallurgical examination. The initial

examination by Pacific National found a crack in the rim extending from a

crack on the tread (see Figure 3). The brake shoe was not overhanging the

wheel tread face. Brake shoe overhang had previously been identified by

Pacific National as a contributory factor to wheel rim defects.

Source: Pacific National, annotated by OTSI

Figure 3: Cracking in wheel tread

1.4 Comsteel were the manufacturer of the wheel and considered the most

appropriate organisation to conduct the metallurgical examination. The scope



for metallurgical examination of the cracked wheel was prepared by Pacific

National for Comsteel and included the following requirements:

Visual examination,

Tread profile measurements at four locations around the tread,

Magnetic Particle inspection, and

Ultrasonic inspection.

1.5 The wheel was sent to Comsteel in Waratah, NSW for metallurgical

examination.

Wheel information

1.6 The wheel was originally supplied in April 2007 to United Group Rail Maintrain

to the specification AAR M - 107 B MOD (Microalloy B Material). Since the

time the wheel entered service until the incident on 1 April 2019, this wheel

had travelled approximately 1,170,000 km. See Figure 4 for wheel

manufacturing details.

Category Details

Manufacturer Comsteel

Type: RLN4.5-212

Heat No.: C37043

Grade: AAR M107 Class BM

Batch: WDZ

Serial No.: 06021468

Despatch date: 24 October 2006

Source: Pacific National

Figure 4: Manufacturing records for wheel



Related incidents

1.7 ONRSR Safety Bulletin. There were two identified Pacific National wheel

incidents in 31 May 2013 and 25 August 2013 and, as a result, ONRSR

published a Safety Bulletin in June 2014. It was titled: An emerging issue:

‘shattered rim’ wheel defects, and is included at Appendix 3.

1.8 The bulletin stated that ‘the failure mechanism is usually the result of rolling

contact fatigue initiating from a subsurface tread defect or inclusion’. The

safety bulletin reminded operators to question current maintenance and

wagon inspections and enhance wagon maintenance for those wheelsets

which are approaching the condemning diameter.

1.9 Failed wheel and derailment, Pangela, NSW, 2015. In 2015, a loaded

Pacific National coal train MB520 derailed at Pangela. The ATSB investigation

determined that the derailment was the result of a fractured wheel on the

leading right hand wheel on the 19th wagon. 3 This led to the wheel moving off

the wheel seat towards the centre of the axle. The train continued travelling

until a damaged inter car brake cable activated an automatic application of the

train’s brakes. There were no injuries, but the derailment caused damage to

over 590 m of track including 963 sleepers.

1.10 The Pangela investigation found that the wheel inspection processes were not

effective in detecting surface damage or cracks. The failed wheel was

approaching the end of its service life with a rim thickness of 25 mm (see

Appendix 2 for an explanation of how rim thickness is measured). This low rim

thickness increases propensity for thermal distortion and is likely a significant

factor into the thermal crack formation and propagation that occurred.

1.11 A metallurgical analysis conducted after the Pangela derailment found that the

wheel had multiple cracks in the wheel rim. Thermal cracks of this type are

generally associated with high thermal input under service brake conditions.

In Figure 5: Image 1 shows the location of the thermal cracks in relation to the

fracture. Image 2 identifies thermal cracks located on the front face of the

wheel tread.

3 ATSB Rail occurrence investigation report RO-2015-015 Derailment of freight train MB520 – published 20

June 2016.



Source: Comsteel, annotated by OTSI

Figure 5: Thermal cracks identified on wheel at Pangela NSW (2015)

1.12 Low rim thickness was a contributory factor in six earlier Pacific National

wheel cracks incidents between 2013 and 2016. The rim section thicknesses

ranged between 22 – 26 mm. Following the derailment at Pangela, Pacific

National implemented a program to remove wheels with a rim thickness under

25 mm. The rim thickness of the cracked wheel at Greta was 32 mm, within

Pacific National’s stated acceptable range.

Remedial actions

1.13 Pacific National have notified OTSI that they have undertaken the following

remedial actions:

a. A revised process for communication between Pacific National and

maintenance contractors has been put in place. Identified personnel

have been trained in the revised processes to ensure the reasons for

wheelset removal is understood.

b. A review of the Wagon Maintenance Manual (WMM 09-05) was

undertaken. It was amended to include shelling and spalling defects.

This required that the rim edge be marked and tested with magnetic

particle inspection after turning, to ensure complete removal of defects.



c. Assurance / surveillance activities are now conducted bi-annually. The

previously specified time period was 12 months. Sites are audited

against Pacific National wheelset overhaul standards.

d. Non-conformance items identified in audits are managed internally in

the Pacific National Safety Management System. Actions are

monitored for effective closure.



PART 2 ANALYSIS

Wheel examination

2.1 Comsteel prepared the failed wheel for assessment and completed a

metallurgical report for Pacific National in December 2019.4 The metallurgical

information in this section is based on the Comsteel report.

2.2 The wheel was intact when it was received by Comsteel where it was

subjected initially to a visual examination. The visual inspection found that

significant wear had occurred on the wheel tread. There was a field side ridge

on the tread approximately 40 mm from the front rim face (see Figure 6).

There was no sign of flange wear.

Source: Comsteel, annotated by OTS

Figure 6: Field side ridge and tread cracks on Greta wheel

Two wheel profiles of the cracked wheel were taken using a rim profiling

device. A profile of the wheel was taken in the area of the tread defect and

then again 180° on the opposite side of the wheel. The recorded profile of the

wheel was compared against the original wheel profile template. This showed

4 Comsteel Customer Quality Report No. 2388957, Examination of cracked rim RLN4.5-212 Wheel Pacific

National Wagon NHRH50260, prepared December 2019.



any deviations from the original profile. The rim profile in Figure 7 shows two

wear zones either side of a field side ridge at about 40 mm from the rim face.

This profile was taken from the area at the tread defect. Both wheel profiles

taken at 0° and 180° exhibited defined wear zones on either side of the field

side ridge, indicating the worn wear profile was likely present before the wheel

failed.


Figure 7: Outboard side ridge and tread cracks on Greta wheel

2.3 Previous profiles supplied by Pacific National, taken four months before the

incident, showed no evidence of wear.

2.4 The worn wheel profiles indicate that this wheel had been tracking centrally

about the tread line. This is an area where the highest concentration of

wheel/rail contact stress cycles and is a likely location for subsurface rolling

contact fatigue cracking to occur. The other wear zone towards the front face

may have been the result of plastic deformation of the metal caused by forces

in other areas acting on the tread face.

2.5 The wheel was cleaned with a 5% nital solution (nitric acid and alcohol) and

inspected. This solution is used to reveal the microstructure of carbon steel



during microscopic assessment. There was no white etch layer detected.5

White etch layers have been observed on rail running bands for more than

half a century. They are brittle and are known to act as crack initiators. They

are about three times harder than the traditional rail steel used.

2.6 A mechanical saw cut was made in the wheel and the residual stress in the

rim of the wheel was determined in accordance with BS5892 Part 3. There

was a measured contraction of 2.9 mm. This level of compression indicated

that there was no excessive heating of the wheel rim during service

operations. Excessive heating of the wheel rim is a potential contributing

factor to this type of failure, but based on the result of the test described, it

was discounted as a contributory factor.

2.7 A magnetic particle inspection was conducted on the surface of the wheel.

This indicated the presence of subsurface damage from rolling contact fatigue

in the flange float area and thermo-mechanical cracks across the tread in the

area between the two visible cracks. There were cracks detected in the rim

face and rim back extending approximately 110 mm from the rim into the plate

(see Figure 8).


Figure 8: Magnetic particle inspection on Greta wheel

5 Wear (2016) Influence of the initial surface state of bodies in contact on the formation of white etching layers under dry sliding conditions.



2.8 Ultrasonic testing was conducted on the wheel tread and the rim back face.

There were no other defects detected other than the visible cracks and there

were no other non-complying indications detected in the wheel. The ultrasonic

tests showed the maximum depth of the discontinuity in the area below the

visible crack on the front rim face was approximately 16 mm (see Figure 9).

Other than the crack area, the wheel complied with the requirements of

AAR M107 for carbon steel wheels.6

Source: Comsteel

Figure 9: Ultrasonic test markings on Greta wheel showing discontinuity depth (mm)

2.9 Atomic emission spectroscopy was used to determine the chemical

composition of the wheel. Analysis showed the wheel complied with AAR

requirements.7 The composition of the wheel is shown in Figure 10.

6 Association of American Railroads M-107. 7 Association of American Railroads, AAR Manual of Standards and Recommended Practices Wheels

and Axles Wheels, Carbon Steel Specification M-107/M-208, Pueblo, CO: Transportation. Technology Center, 2011.



C Si Mn P S Ni Cr Mo Cu V

0.62 0.87 0.74 0.009 0.014 0.12 0.11 0.032 0.25 0.083

Source: Comsteel

Figure 10: Chemical composition of Greta wheel

2.10 Assessment of the microstructure showed typical pearlitic structure with fine

grain ferrite at the boundaries (see Figure 11). There was no indication of

microstructural abnormalities and there were no large or abnormal non-

metallic inclusions found in the vicinity of the crack initiation site (see Figure

12).

Source: Comsteel

Figure 11: Mircostructure at initiation point exhibiting a typical pearlitic microstructure with fine grain boundary ferrite



Source: Comsteel

Figure 12: Cross section at the initiation point. No indication of non-metallic inclusions on the crack surface. Magnification X100

2.11 A rim cross section was removed next to the rim crack. A Brinell hardness test

was conducted in locations 9 mm away from the surface (see Figure 13). The

determined hardness values complied with the specified hardness range of

302 - 363 HBW (Brinell Hardness Scale) for class BM wheels.



Source: Comsteel

Figure 13: Brinell markings on Greta wheel

2.12 Micro hardness readings were taken on the wheel tread on the tread line and

27 mm from the front rim face (see Figure 14). There were higher hardness

readings on the tread line, which suggested work hardening had occurred

during service.



Source: Comsteel

Figure 14: Micro hardness reading on Greta wheel

Wheel maintenance

2.13 The wheel was re-profiled approximately every 3 years and 280,000 km. The

previous three wheel re-profiles were in July 2010, August 2013 and March

2016. Measurements were also taken following the incident in April 2019.

Information about the wheel at each of these stages is shown in Figure 15.

Date Distance

travelled

Incoming

rim

thickness

Outgoing

rim

thickness

Outgoing

wheel

diameter

Incoming

defects

Jul 2010 Not available 55 mm 49 mm 908 mm Nil

Aug 2013 Not available 45 mm 42 mm 890 mm Thermals

Mar 2016 266,300 km 38 mm 34 mm 876 mm Spalls

Apr 2019 308,061 km 32 mm na 870 mm Cracked

Figure 15: Wheel data at re-profiling intervals and incident date on Greta wheel



2.14 The specified range for the original machined wheel diameter is 920 mm to

926 mm. The condemning diameter for this wheel is 850 mm. At the time of

the incident, the wheel diameter was 870 mm and within the acceptable

dimensional range.

2.15 Pacific National examined, and provided to OTSI, the maintenance records for

this wheelset (1G6S9862). A key record provided was Pacific National Work

Order Number 1271225. The work order, dated 23 February 2016, identified

the reason the wheel was removed from service with a code ’69 – thermal

cracks extending into the plate’ allocated for axle 4. However, the

maintenance contractor, on their maintenance service records, applied the

label ‘spalling’ to Incoming Wheel Defects Category.

2.16 As a result of the different label, the wheel was not subject to non-destructive

testing before it returned to service. A non-destructive test was only required if

a thermal code was applied to the wheel defect. It should be noted, the

metallurgical report into the wheel defect found that a subsurface defect, not a

thermal crack, initiated the wheel crack found at Greta on 1 April 2019.

Wheel impact load detection

2.17 Wheel Impact Load Detectors (WILD) measure the force of impact on the

track caused by each wheel in the train consist passing over the sensors. This

can provide early detection of wheel defects such as skids and wheel out-of-

round. The WILD was originally installed to detect wheel defects that

introduced damaging impact loads to the track.

2.18 The network access provider, the Australian Rail Track Corporation (ARTC),

operate and maintain the wayside monitoring systems in the Hunter Valley

where this incident occurred. There are different types of wayside devices

including detectors for hot bearings, wheel impact loads, acoustic wheel

monitoring, dragging equipment, door closed positioning and weighbridges.

These trackside systems are primarily used by ARTC to prevent damage to

the track infrastructure. They detect a variety of rollingstock and track faults

and are positioned at strategic locations in the network (Figure 16).



Source: ARTC – annotated by OTSI

Figure 16: Wayside monitoring equipment in the Hunter Region, NSW

2.19 The WILD data was examined for this wheelset from the Hunter Valley area

where this wheel mostly travelled. This indicated increasing impact loads from

early March 2019. This likely indicated the early stage of the crack in the

wheel. The data indicated peak impact loads on the wheel of less than 200 kN

prior to the crack being detected. The Pacific National specification only

requires WILD results to be monitored when impact loads exceed 200 kN.8

2.20 The other wheelset, position 3 on the bogie, was also inspected following the

detection of the crack. The wheel profiles of both wheels showed no issues

and the WILD data found no wheel impacts exceeding the specified limits.

8 Pacific National, Wagon Maintenance Manual - Management of Wayside Condition Monitoring Systems, WMM 01-12 _ 02, 2009.



PART 3 FINDINGS

From the evidence available, the following findings are made with respect to the rail

wheel defects on Pacific National freight service T401G found at Greta, NSW on 1

April 2019.

Contributing Factors

3.1 Examination of the failed wheel revealed the cracking to be likely the result

of subsurface rolling contact fatigue failure.

3.2 The rim cracking had multiple fatigue initiation sites located at different

depths across the tread face and different distances from the wheel tread.

Seven fatigue crack initiation sites were detected.

3.3 It is likely that maintenance processes were ineffective in allowing this

wheel to return to service with an identified defect after undergoing wheel

maintenance in 2016.

Other Findings

3.4 The chemical composition and mechanical properties of the wheel met all

required standards.

3.5 There were no substantial non-metallic inclusions found in the wheel.

3.6 The rim thickness was within the acceptable range of Pacific National’s

specification for wheels to remain in service.



PART 4 RECOMMENDATIONS

To improve the safety of its operations and prevent a recurrence of this type of

incident, it is recommended that the following remedial safety actions be undertaken

by Pacific National.

4.1 Evaluate the existing processes for communication between Pacific National

and maintenance contractors to ensure that the reasons for wheelset removal

are accurately conveyed.

4.2 Evaluate the effectiveness of the current standards relating to the detection

and treatment of wheel defects.

4.3 Review the non-destructive testing requirements for wheels in the Pacific

National Wagon Maintenance Manual and ensure the requirements are clear

to maintenance contractors.

4.4 Conduct regular surveillance audits on wheelset maintenance practices,

including non-destructive testing processes, to ensure compliance with Pacific

National’s specifications.

4.5 Conduct regular surveillance audits on wheelset maintenance record-keeping

to ensure the correct coding is applied to wheel defects.

4.6 Ensure that any non-compliance or recommendations from these audits are

closed out.

4.7 Assess the frequency and effectiveness of audits conducted on contractors to

provide for satisfactory assurance that wheelsets are being inspected

according to industry standards and internal specifications.



PART 6 APPENDICES

Appendix 1: Sources, Submissions and Acknowledgements

Sources of Information

ARTC

Pacific National

ONRSR

TfNSW

References

Asset Standards Authority NSW (2013). Wheel defect manual. May 2013.

Australian Rail Track Corporation (2014) Wheel Impact Load Detection (WILD)

Alarm Specifications, Version 2.0, 12 March 2014.

Comsteel (2019) Customer Quality Report CQR 2388957, Examination of

Cracked Rim, RLN4.5-212 Wheel Pacific National Wagon NHRH50260,

December 2019.

Mutton and Laczko. (2006) Metallurgical and NDT aspects in the management

overheated railway wheels. MATe05 paper.

Office of National Rail Safety Regulator (2014). An emerging issue ‘shattered rim’

wheel defects. Safety Bulletin No. 3 June 2014.

Pacific National (2009). Management of Wayside Condition Monitoring Systems,

Wagon Maintenance Manual. 01-12_02.

Pacific National (2019) Operational Risk Register ORR NSW-Vic.

Rail Industry Safety and Standards Board (2010) Glossary of Rail Terminology –

Guideline.

Rail Industry Safety and Standards Board (2018) AS 7514:2018 Rolling stock

standard – Wheels.

Rail Industry Safety and Standards Board (2018) AS 7517:2014 Rolling stock

standard – Wheelsets.

U.S. Department of Transportation Federal Railroad Administration (2014)

Broken Rims in Railroad Wheels.



Wear (2016) Influence of the initial surface state of bodies in contact on the

formation of white etching layers under dry sliding conditions.

Submissions

The Chief Investigator forwarded a copy of the Draft Report to the Directly Involved

Parties (DIPs) to provide them with the opportunity to contribute to the compilation of

the Final Report by verifying the factual information, scrutinising the analysis,

findings and recommendations, and to submit recommendations for amendments to

the Draft Report that they believed would enhance the accuracy, logic, integrity and

resilience of the Investigation Report. The following DIPs were invited to make

submissions on the Draft Report:

ARTC

Pacific National

ONRSR

TfNSW

Submissions were received from the following DIPs:

Pacific National

ONRSR

The Chief Investigator considered all representations made by DIPs and responded

to the author of each of the submissions advising which of their recommended

amendments would be incorporated in the Final Report, and those that would not.

Where any recommended amendment was excluded, the reasons for doing so were

explained.



Appendix 2: Wheel information

Source: Asset Standards Authority

Figure 17: Standard terminology for wheels

Source: Asset Standards Authority

Figure 18: Measuring the rim thickness

In this example, the rim thickness is 48 mm.



Appendix 3: ONRSR Safety Bulletin





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