Sydney Trains acknowledges that the inaccuracy of the Special Train Notice (STN) and relevant rules and procedures not being followed during implementation of the LPA were contributing factors to this incident. Sydney Trains undertakes assurance activities in relation to safety critical communications; these include checking of audio recordings of these conversations.
Sydney Trains proposes to undertake targeted assurance in relation to adherence to safety critical communications protocols in LPAs in order to determine whether the non-compliance's revealed in this investigation represent a systemic failure. Should systemic failures be identified further investigation will be undertaken.
The Australian Transport Safety Bureau recommends that Sydney Trains takes further safety action to address to what extent the inherent safety and efficiency of Local Possession Authorities can be compromised by non-compliance with rules and procedures by key stakeholders and if evident, whether they represent a systemic failure.