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2014 Risk Analysis Report Client: Yarra Trams Contractor: Risk Removals Ltd Location: Melbourne, Australia

Risk Analysis Yarra Trams

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Page 1: Risk Analysis Yarra Trams

2014 Risk Analysis Report

Client: Yarra Trams

Contractor: Risk Removals Ltd

Location: Melbourne, Australia

Location: Melbourne Australia

Page 2: Risk Analysis Yarra Trams

INTRODUCTION AND PURPOSE

Description of the Assignment:

Risk Removals Ltd. is an experienced firm in the Risk Management Industry.

Based in Australia, Risk Removals operates in the Melbourne Metropolitan precinct and operates as a service

provider on a contractual basis. Risks Removals main focus is on identifying and working on projects within the

Metro sector that contain extensive technical and/ or commercial risks.

KDR Victoria Pty Ltd has approached us on behalf of their Yarra Trams division to qualitatively perform a risk

assessment evaluation on the Operations and Maintenance of their new E class trams.

This assignment aims to collate qualitative data in the form of a report that will outline the Scope of the

Operations and Maintenance (hereinafter referred to as O&M), the risk analysis tasks undertaken and the final

evaluation and treatment of the identified risks.

The main emphasis is on the following:

- Identifying at least 8 risks in the context of O&M

- Performing a Qualitative risk analysis through a workshop format

- Using a Qualitative risk analysis matrix to categorize risks based on a 2 dimensional risk factor rating

system (likelihood & consequence)

- Evaluating risks Determining treatment & priorities Recommending monitoring & review

procedures per risk.

The ‘AS/NZS ISO 31000:2009 Risk Management – Principles and Guidelines’ standard will be utilized throughout

this assignment as a reference.

Objectives of the Assignment

Through undertaking this Risk assessment assignment, the following objectives are to be met:

- Raising awareness of the need to identify and treat risks

- Increase levels of Stakeholder confidence and trust through risk reduction procedures

- Initiating or enhancing controls

- Effectively recognize and utilize resources for risk treatment

- Highlight the significance of Health and safety as well as Environmental protection

- Recognize loss prevention and improving incident management

Page 3: Risk Analysis Yarra Trams

EXECUTIVE SUMMARY

To Identify, assess, treat and monitor prevalent and hidden risks in the operation and

maintenance of the Yarra trams within the context of the E class sector. Primary research was

undertaken by Team A. This involved consultation of engineering representatives of Yarra

trams and ground support staff; whereas Team B followed through with secondary research

methods, such as usage of the internet. 8 risks with associated controls were identified; they

range from passenger belonging damage to onboard fires. As for the assessment process,

ISO 31000:2009 was used as a benchmark during the identification, analysis and evaluation

process. The treatments were also formulated with the standard in mind; as such they have

been designed with a treatment plan as well.

The findings and recommendations section outline the residual risk and related mitigations.

Our final recommendation is that Yarra Trams should implement all the possible mitigations

that we have proposed within this Risk Management report. Furthermore we would strongly

recommend an annual risk re-evaluation as part of the monitoring and review process

outlined in ISO 310000:2009.

CONTEXT OF ANALYSIS

The advent of Yarra Tram’s E class is representative of Melbourne’s rich history, Architecture and Design (Design

Institute of Australia, 2014) and its continuous evolving presence on the global stage as a modern metropolis.

These state of the art trams are the longest in Melbourne at 33m with a capacity of 210 passengers. The arrival

of the new E class trams was announced to the public on the (Public Transport Victoria, 2013a) 17th April 2012 by

The Hon. Terry Mulder, Minister for Public Transport in Victoria, and on the 4th November the first official public

run was held. These next generation trams have been dubbed as ‘E for everyone’ trams and are part of The

Victorian government’s Tram procurement program (Public Transport Victoria, 2013b).The program endeavors

to:

- Purchase and Operate 50 low-floor trams (E class)

- Revamp the existing route 96 line by improving accessibility for individuals with disabilities.

- Renovate the Southbank and Preston Tram depots which will house the new E class trams.

The trams are assembled at the Bombardier Rail Vehicle production site in Dandenong; this has resulted in the

creation of 50 new jobs (Public Transport Victoria, 2013b). Although only 5 out of the planned 50 Bombardier

Page 4: Risk Analysis Yarra Trams

trams are operational along route 96, once all 50 trams are in service, the capacity will increase by 10,500

passengers per day (Public Transport Victoria, 2013a).

Each E class tram costs six million dollars. The total cost of the E class project’s implementation is estimated at

exceeding $800 million and is expected to be completed by late 2017.

The E class O&M project is intrinsically fragile; the cost of the implementation is immense, the nature of the

service (transport) means that passenger safety is of utmost importance and the high probability of external

influences affecting the availability of the services are only a few reasons why this project is ideal for an in-depth

qualitative risk management exercise.

Finally, this report is intended for use by the Operations manager of Yarra trams and the scope in terms of the

period under consideration for this risk management report is continuous. Key stakeholders range from

commuters (consumers) to staff and management. As a result, risks could range from physical accidental

damage to intangible financial losses, which could alter the balance of resources, thereby increasing the chances

of similar events occurring repeatedly.

METHODOLOGY USED & KEY STAKEHOLDERS

INVOLVED

Risk Removal (PVT) LTD is a well reputed company in Melbourne which follows the all standard Risk

Management - Principles and Guidelines stated in the AS/NZS ISO 31000:2009. Hence this section was also

conducted as pre-specified.

As advised by our client: Mr. Ramesh Liyanagedera (Director of Infrastructure & Director of Operational

Performance - Yarra Trams (Keolis DownerEDI Rail)), the basic boundaries of this quantitative risk analysis was

defined and a quite a minor research on the company external and internal environments.

The next stage was to identify the hazards, their respective risks and the current mitigations implemented. So we

divided our project team into two groups A and B. Team A was responsible to gather risks the analysis of past

records and incidents regarding trams while team B was responsible to gather information from the field by:

1. Questioning the passengers for the risks that they had faced

2. Interviewing tram drivers

3. Interview with an Engineer at Yarra Trams

4. Information from public relation officer

Now with almost all of the hazards and their risks identifies the next step was to analyze the risk by evaluating

the consequences and likelihood of the risk based on the statistics found by team A. Each of the risks was rates

according to the predefined risk criteria and the risk matrix found on page (The page which contains the

consequence n likelihood table). And then the risk were prioritized according to their ratings

Page 5: Risk Analysis Yarra Trams

Figure 2: Tram collision at Graham St overpass

(2007)

With this stage completed, we started brainstorming on more effective mitigations to treat the risk identified.

And once the new treatment methods were all sorted out, a treatment plan was made per each risk.

It must be noted that, due to the lack of statistical information regarding E class trams, data from other incidents

relating to trams was obtained and utilized in some sections of this assignment. This is following the underlying

assumption that a tram will always have certain unavoidable hazards in all cases.

Finally as the last stage, the new mitigations were monitored and reviewed. Any remaining residual risk were

identified and treated.

IDENTIFIED RISKS: DESCRIPTION AND EXISTING

CONTROLS

Hazard: Mixed traffic

Risk: Accidents which include:

- Tram and tram collision,

- Tram and other vehicles or public collision

- Tram and infrastructure collision.

According to Yarra trams, the average speed of trams is 16 km/h and the maximum speed of the new E class

tram is 80 km/h. So there is a chance of accidents in the shared roads. Transport safety of Victoria website

published the statistics of the various types of accidents. The table below shows their findings.

Existing Controls::

- Awareness is created among the people to obey the traffic

rules

- More road signs are placed

Occurrence

type

Category

type

2008 2009 2010 2011 2012

Collision Person 7 9 7 2 2

Road Vehicle 1 2 6 4 3

Infrastructure Not enough statistics

Derailment Running line

derailment

1 1 0 1 0

Miscellaneous Vehicles

passing

stationary

trams

0 1 0 0 0 Figure 1: Rear tram collision at St. Kilda st

Table 1: Adopted from transport safety website

Table 1: Adapted from Transport safety website

Page 6: Risk Analysis Yarra Trams

0

10

20

30

40

50

2008 2009 2010 2011 2012

Running derailment

Runningderailment

Figure 3: Statistics of derailment in Melbourne

Figure 4: Statistics on fire incidents within tram.

Adapted from Transport Safety Australia

- More service staffs are put on duty in the busy roads to avoid collision with pedestrians like in front of

Myer in Bourke st for route 96.

Hazard:

Wheel worn off beyond limit/ axle failure/over

speeding/coupling failure

Risk:

Running line Derailment

Wearing away of wheels beyond limit, axle

failures , coupling failures as well as over

speeding could lead to a huge possibility of

trams derailing., which then could lead to a

wide range of other accidents dues to the

derailment which includes tram to tram

collisions, tram to vehicle collisions, tram to

pedestrian collisions etc.

Existing Controls:

Comprehensive check up every two months.

Hazard:

Electricity leakages from the power line onto

the trams

Risk:

Fires on trams

There is always a chance of electricity leaking

on the trams from the power cable above,

which then opens up the possibility of fires

within tram when this residual electricity reach

the electric equipment within the trams.

Existing Controls: Fire extinguished installed in

trams.

Page 7: Risk Analysis Yarra Trams

Figure 5: E Class complaint [Screenshot]. (2014).

Figure 6:Damaged belongings complaint (Swanston st- Bourke St intersection) [Screenshot]. (2014).

Figure 7: Accident location(Swanston st – Bourke St intersection) [Photograph]. (2014).

HAZARD: Sudden stops

Unwarned stops are a common occurrence with trams. The hazard could be caused by many factors; examples could be:

Drunken pedestrians crossing tram tracks illegally, Vehicles overtaking trams improperly or even drivers temporarily getting

distracted by passenger behavior. Sudden stops give rise to many risks, few of which will be detailed here:

Risk 1: Passenger falling due to inertia resulting in injured passengers

On the 27th

March 2014, a Yarra Trams consumer lodged a complaint via

Facebook regarding many issues facing the E class trams. One major concern

that she touched upon was the poor ergonomic design of commuter support

handles in the context of sudden stops. She says ‘..and there are multiple spots

where you can't hold on to anything to prevent yourself from falling? Do you

think everyone is tall enough to teach the overhead bars?... And when you

can't reach anything to hold on to, it's really ironic when you hear an

announcement on the speakers going "please hold on as sudden stops are

sometimes necessary". There's nothing to hold on to!!!(Chong, 2014).’

Existing Controls: Passenger support installed

Risk 2: Damage of passenger items

Another risk involving sudden stops is the possibility of damaging commuters’ personal belongings. Trams in the

metropolitan area travel at an average speed of 11 km per hour (Yarra Trams, 2014). However, tram drivers do have a

tendency to unexpectedly accelerate and maintain a moderately high speed of around 20 – 30 km per hour. In such cases, a

sudden stop could result in personal belongings falling from the passengers hand or lap and potentially breaking.

In the following account, a passenger details her misfortunate happening when her laptop broke due to a sudden stop:

‘Hi Yarra Trams, I want to know how I can contact you about damage to my personal property, caused by a sudden stop

and a subsequent fall. I was traveling on a tram on Bourke Street; on Wednesday 13th

November (it was an extremely rainy day and as a result more people than usual were

using the tram). The driver braked suddenly at the Swanston/ Bourke Streets

intersection, causing me to fall (my boyfriend and a stranger came to me assistance),

as a result my laptop screen has been cracked inside and over half of the screen does

not work.(Jayne, 2013)’

Existing Controls: Safety brochures already

provided.

Page 8: Risk Analysis Yarra Trams

Hazard: Brake pads wearing out

Risk: Accident

Due to extensive use for a longer period of time, wear and tear of the brakes is expected in the trams.

So there is a risk of accident if the brakes are not fixed routinely. Accidents may include hitting other

trams from back, failing breaks at signal and failing emergency brakes as well. An example of such

accident is adopted from Herald Sun (Melbourne, Australia), June 2, 2000 News 2 - SECOND, p. 023

1pp which said "Thirty old W-class trams have been withdrawn from public use because of safety risks

after a serious tram accident yesterday. A tram driver was trapped in his crushed driving cabin for half

an hour after the tram he was driving slammed into the back of another tram in the city. The accident,

which occurred about 4pm near the corner of St Kilda Rd and Albert Rd, is believed to have happened

after the brakes on the W-class tram brakes failed..."

Existing controls: Regular maintenance and repair.

Risk: Health issues, unpleasant travelling experience, less customer satisfaction.

According to Yarra tram website, trams operate for more than 20 hours a day and the annual patronage for

2012-13 was 182.7 million boarding. These figures show how extensively trams are used in Melbourne as a

means of transport. Hence a hygienic and clean tram travelling environment is of great concern for the

operational and maintenance authority of Yarra trams. Especially during the weekend nights the trams become

really dirty and due to the boarding of lots of drunk people the environment becomes unpleasant for many

specially for the children. Therefore there are issues with health and safety and customer satisfaction which

affect the reputation and the income of the Yarra trams. Besides graffiti is also a concern for tram maintenance.

This destroys the look and beauty of trams for which Melbourne is famous.

Figure 8: Graffiti at the body of the brand new tram.

Figure 9: Scratches beside the tram seat

Figure 8 and 9 showing the extent of damage caused

during the first week of operation

Page 9: Risk Analysis Yarra Trams

Hazard

Tram Drivers

Trams drivers can often be under a lot of stress. Mostly at

the last hour of their work period or the last trip, they

rush to finish the day.

Any fit driver can suddenly grow a physical/mental

condition. It might be some work related injury or an

abrupt health condition such as stomach/intestinal

disorder, muscular (back, neck, shoulder, knee) or some

problems unwinding at home/sleeping disorder that’s

affecting his mental state causing disorders like

tension/anxiety/depression/aggression/fatigue.

In heavy traffic congestion a driver can become frustrated pressing the

accelerator and brake pedals an awful lot of times leading to a sore knee

and foot. These could result in wrong judgement and mixing up the

pedals in crucial times. For sometimes the driver’s age could also be an

issue. They might not be fit and mentally capable enough to carry on

with the job. Work environment that is the drivers cabin should be be

comfortable enough, not causing further distractions.

Existing Risks

Consequences may be fatal causing accidents such as collisions, not

noticing boarding/disembarking passengers while closing doors, inaccurate judgement of traffic lights and

pedestrians and sudden stops. There was even an incident where the driver was flicking through a catalogue

while the tram was in motion.

Existing Mitigations: Regular health checkups

Figure 10: Driver’s cabint in the E class tram.

Figure 11: Graffiti at the body of the brand new tram.

Page 10: Risk Analysis Yarra Trams

HSE Risk Matrix[Screenshot]. (2014).

RISK ASSESSMENT: LIKELIHOOD AND CONSEQUENCE

Risk: Tram Collisions

Consequence: catastrophic (5)

The severity of the accidents range from injuries to death as well. The pictures above also depict the

consequence of to the accidents. So this is rated as catastrophic due to its significant damage.

Likelihood: Possible (3)

According to the statistics, we have an idea of the frequency of the accidents and we say the likelihood to be

possible.

Overall rating: Extreme

Risk: Running line derailment:

Consequences: Major (4)

According to the past history on tram derailments, it was recorded that such tram derailment caused huge

financial losses due to major accidents involving trams and other vehicles. Furthermore it was also found that

such accident did also lead to severe injuries on passengers. Hence this risk is considered to have a major

consequence.

Likelihood: likely (4)

The statistic on tram derailment over the past few year indicate that tram derailments are likely. Specially

because there have been almost over 30 incidents recorded over each of the past 7years. (Refer to figure 3)

Overall rating: EXTREME

Page 11: Risk Analysis Yarra Trams

Risk: Fires on trams

Consequences: Major (4)

According to the statistics from the past few years, the fire accidents reported are gradually increasing. Well in

2011 there was a single case reported while in 2012 there were two fires reported in trams. Such an incident

could lead to serious injury to the passengers hence it is considered to have a major consequence. (refer to

graph 1)

Likelihood: Possible (3)

As predicted from the previous statistics it is possible that there can be a fire within any tram.

Overall Risk Rating: HIGH

Risk : Passenger falling off resulting severe injures

Likelihood: 4

Consequence: 3

Although statistical data relevant to this risk was unavailable, upon browsing the internet we came across three

direct complaints on Yarra Tram’s Facebook page relating to the said risk. Members of the Risk Removal team

are also users of public transport, including the tram services; during their journeys they would experience falls

and witness other passengers getting injured by falling. As a result, the likelihood rating was set at 4. The

consequences of a fall would not result in death or multiple injuries, however it may result in a serious injury

requiring hospitalization. As a result, the consequence rating was set at 3.

Overall Risk Rating: HIGH

Risk : Damage of passenger items

Likelihood: 2

Consequence: 3

Although statistical data relevant to this risk was unavailable, upon browsing the internet we came across one

direct complaint on Yarra Tram’s Facebook page relating to the said risk. The likelihood of this occurring is

unlikely; however there remains a possibility that occurrences such as this may materialize, hence the likelihood

rating of 2. As for consequences, the damage of consumers’ property is taken seriously, however it does not fall

under category 4 or 5 due to its unharmful nature. The potential for a lawsuit is valid and as such the

consequence rating is rated at level 3.

Overall Risk Rating: MEDIUM

Page 12: Risk Analysis Yarra Trams

Risk: Accidents due to wearing out of brake pads

Consequence: catastrophic (5)

The consequences of the accidents due to brake failure range from extensive injuries to death. So the

consequence of brake failing is catastrophic.

Likelihood: Unlikely (2)

Overall rating: MEDIUM

Risk: Health issues and customer dissatisfaction due to unhygienic tram environment

Consequence- Moderate (3)

Herald Sun News reported “Graffiti vandals trash Melbourne's new E-Class trams" in November 2013.

The news also said that two seats of the tram were damaged at the same time and this incidence took

place in less than a week the trams were introduced. (Picture 1 and 2 shows the evidence of the

incident.) And couple of maintenance staffs of Yarra tram said "Graffiti is really annoying for us. This

happens sometimes." They also said that during the weekend nights cleaning is a hard job for them. So

the consequence is moderate bearing in mind that it is hard to stop the drunk people but it is

comparatively a bit easier to treat the damage done. But it requires some media attention.

Likelihood: Almost Certain (5)

As people get drunk at every weekend, it is not possible to eliminate the risk entirely and it is expected

to happen. So there is a health and safety issue and also a risk of graffiti.

Overall rating: HIGH

Risk: Irresponsible tram drivers

Consequence- Major (4)

The incident recorded due to irresponsibility of tram drivers are mostly severe incidents leading to huge

financial losses as well as major passenger injuries. Hence this risk is considered to have Major

consequences.

Likelihood: Unlikely (2)

Even though the consequences from this particular risk is quite high, only a very few incidents were

recorded over the past decades, which confirms that it is unlikely to face this risk.

Overall rating: HIGH

Page 13: Risk Analysis Yarra Trams

RISK TREATMENTS AND PROPOSED

IMPLEMENTATION

Risk Treatment Treatment Plan

Tram Collisions 1. Railings should be placed to separate the

tram tracks from the road especially in the

dangerous zone.

2. Alternative routes should be built to avoid

traffic congestion.

3. More cameras should be installed to

discourage signal violation.

1. More budgets should be

allocated.

2. Records should be kept

precisely and the accidents

should be investigated to find

the reasons of the accidents

and then necessary steps

should be taken to minimize it

in the future.

Running line

derailment

1. More frequent overall check-ups on trams

2. Penalties on tram drivers who exceed the

speed limits

3. More advanced training on to the

mechanics

1. As the initial stage we could

implement more frequent

regular tram check-ups. While

at the same time we too could

launch laws to apply penalties

to tram driver who drive over

the speed limit. Finally

introducing modern

technology onto the mechanics

would do it.

Fires on trams

1. Training Tram drivers to handle minor

incident which involves fires within trams

1. Tram driver training programs

could be conducted in order to

minimize the chances and the

effects of fires within trams.

Passenger falling off

resulting severe

injures

1. Lower support handles for better

accessibility for the general population

(high priority)

2. Padded cork flooring on new low floor trams

to absorb impact upon potential falling

(low priority)

1. Implementation of this system

could work on a weekly basis

with a select amount of trams

being retrofitted weekly.

However, it must be noted that

potential barriers such as cost

could undermine the

enactment of these treatments.

Page 14: Risk Analysis Yarra Trams

Damage of passenger

items

1. Advise customers to use their valuable

belongings such as mobile phones only

when the Tram is stationary. (High priority)

2. Advise customers to keep their belongings

on the floor next to them (High priority)

3. Install overhead compartments for fragile

items in tram (Low priority)

1. Implementation of this system

could be immediate through

announcements made on

automated announcements

made on every third tram stop

or through high visibility

posters. However, it must be

noted that potential barriers

such as cost could undermine

the implementation of the final

treatment option

Accidents due to

wearing out of brake

pads

1. Regular and more frequent maintenance

should be done.

2. Old trams should be replaced and should

not be used under any circumstances.

3. Staffs should be trained

1. More budgets should be

allocated in repair and

maintenance. 2. More training session should

be arranged and the staffs

should be encouraged to

attend them. Health issues and

customer

dissatisfaction due to

unhygienic tram

environment

1. More staffs should be appointed for the

weekends.

2. CCTV camera should be placed inside the

trams like in new E class tram so that anyone

doing any damage inside the tram can be

recorded.

3. During weekends the trams should be

checked for any alcohol bottles all the time

and should be removed as soon as possible.

1. More workforces should be

recruited

2. Staff working at weekend night

can be paid higher to

encourage them.

Irresponsible tram

drivers

1. Daily rest between two consecutive working

ie. a quality break periods between trips and

a day off/ weekend off.

1. There should be enough

reserve drivers. There should

be regular fitness check-up

before job. Ergonomic layout

of the driver’s cabin. To make

them spontaneous you can

involve them in sports or

arrange some quarterly events.

Page 15: Risk Analysis Yarra Trams

Finding and Recommendations

Residual Risk and Their Mitigations

Risk Residual Risks Mitigations

Tram

Collisions 1. During weekend nights people get drunk

and they drive recklessly which might still

cause accidents.

1. Police patrol in the weekend nights

should be increased to avoid drunk

people coming in front of the trams

or doing any misdeed in the tram

track.

Running line

derailment: 1. Tram drivers exceeding the speed limits

1. Have speed restriction panels

installed within trams, so that trams

cannot reach speeds above the limit

Fires on trams 1. Passengers over reacting during a fire within

a tram.

1. Launching programs for passengers

to make them aware about how

they should react in the case of a

fire within the trams.

Passenger

falling due to

inertia of high

speed

resulting in

injured

passengers

1. Unaware passengers; And there are always

children and aged passengers in the tram

not holding the tram properly

1. Easily visible warning signs

Damage of

passenger

items

1. Compartment load failure if too many heavy

objects are stowed, resulting in potential

major injuries

1. By strengthening supporting

structure to withstand 1.5 times

expected load as a safety factor.

Accidents due

to wearing

out of brake

pads

1. Operation and maintenance staffs might be

irresponsible with their duties.

2. Maintenance might be infrequent due to

the shortage of funds.

1. Inspiring the staffs morally and

allocating more funds.

Health issues

and customer

dissatisfaction

due to

unhygienic

tram

environment

1. Though the new E class trams don’t have

CCTV camera, most of the trams do not

have.

2. There are some graffiti gangs who aim to

target the newly introduced public assets.

3. It is really hard to control the drunken

people.

1. More budgets should be allocated

and more police patrol.

Irresponsibility

of tram

drivers

1. Still there are few tram drivers who are not

morally perfect with their work

1. Giving tram drivers training and

encouraging them to do their work

properly(increasing salary helps in

Page 16: Risk Analysis Yarra Trams

Risk register:

Page 17: Risk Analysis Yarra Trams

REFERENCES

The primary research contact was one of the Engineering representatives from Yarra trams. Their name or

position cannot be disclosed as part of a conditional agreement of anonymity.

Accident location (Swanston St – Bourke St intersection) [Map]. (2014). Retrieved April 4, 2014,

from https://maps.google.com.au/

ADAM CAREY TRANSPORT, R. (2012, August 4).

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ANDREW POTTS & SHAYA, L. (2014, February 19). Tram slams into 4WD.

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Page 18: Risk Analysis Yarra Trams

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Transport safety Victoria. (2014, April). Retrieved

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from http://www.transportsafety.vic.gov.au/__data/assets/pdf_file/0003/87627/2012-Annual-

incident-statistics-Tram.pdf

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