ARTC's network rules did not provide suitable guidance to assess continued safe operation when responding to track circuit faults. Additionally, the network rules permitting signals to be passed at Stop did not require a reduction in speed when the condition of the track was unknown.
The Sydney Trains worksite briefing process did not compel a new work group to seek a worksite protection pre-work briefing when accessing an existing worksite.
The worksite protection method presented an increased risk, in that track workers might inadvertently exit the worksite, and subsequently be in the immediate vicinity of operational main line rail traffic. Sydney Trains network rules and procedures for a Track Occupancy Authority did not manage the increased risk for the chosen worksite protection method.
The network rules and procedures require communications to be clear, brief and unambiguous. Network communications by various parties in Sydney Trains were not in accordance with the principles underpinning the network rules.
Sydney Trains’ work-planning process, involving multiple work groups, did not assure the consideration of worksite safety for all tasks undertaken by each involved party over the duration of the work and when returning the rail infrastructure into service.
Pacific National's training course for the loading and securing of freight, and their verification of competency checks for inspection staff, did not include the Freight Loading Manual requirements for non-standard and modified containers.
While the Freight Loading Manual was available to customers, Pacific National did not actively advise them when they had a responsibility identified by the manual. Further, they did not have a process for ensuring that customers complied with the manual’s requirements.
The rostering of the driver in the days leading up to the incident was inconsistent with Sydney Trains' rostering principles.
Sydney Trains' risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances where the presence of an intermediate train stop at Richmond may have reduced the risk of trains approaching the station at excessive speed.
Sydney Trains’ risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when there were deficiencies in the buffer stop design at Richmond and at other locations.
When A42 collided with buffer stop at Richmond station No. 2 platform, the reinforced concrete end stop of the buffer stop withstood the impact of the collision and prevented the train from crossing into a pedestrian and main road precinct. The two hydro-pneumatic rams on the front of the buffer stop did not perform their intended function. They were not aligned with the front of the Waratah train and instead of absorbing energy from the collision, they penetrated the cavity either side of the front-of-train coupler.
The crash energy management system on the Waratah passenger train A42 reduced the impact force of the collision but not all components performed as designed. The performance of the crash energy management system was significantly limited by the buffer stop at Richmond being incompatible with the front of the Waratah train.
The wiring error was not detected by Metro Trains Melbourne’s verification program.
V/Line did not have a documented detailed process for inhibiting and reinstating level crossing protection equipment.
Lookout Working (LOW) was implemented in an area deemed unsuitable for LOW on the Sydney Trains Worksite Protection Hazardous Locations Register (WPHLR). This is likely due to the WPHLR not being clearly stated as a reference with specific requirements that must be adhered to.
Warning lights were utilised at Tempe to overcome sighting hazards and justify the use of Lookout Working (LOW). Warning lights rely on lookouts maintaining continuous observation and their use were not specifically referenced in the LOW Network Rules.
A variety of techniques to indicate and record rail stress at specific locations are available, however, Aurizon had not used any of these techniques in some locations with elevated risk of rail stress, such as tangent track on steep grades. As a result, Aurizon could not readily determine the presence or absence of compressive rail stress at these locations.
When planning track disturbing work, Aurizon’s normal practice was to use its Hazard Location Register as a record of past occurrences at a specific location. Aurizon did not use the Hazard Location Register as a resource to consider the situational characteristics of a location that may increase risk, such as continuous welded rail, track gradient and proximity to fixed points such as turnouts or level crossings.