The design of the NTCS in screening Adelaide metro broadcast communications prevented the driver of 2MP9 from gaining an appreciation of activities close to his area of operation, in particular the position of train 2MP1 along the Mile End main line.
Vegetation and a low fence adjacent the Mile End crossing loop partially obscured the view that the crew of train 2MP9 had of the empty flat wagons at the rear of train 2MP1.
There were no formal systems in place to manage the accepted practice of Protection Officers leaving a work site to return a Track Warrant and Train Staff, prior to ceasing works, off-tracking and ensuring the line was clear. This practice led to the informal delegation of responsibility for ensuring the track was clear to others at the work site.
Reporting and communications were not carried out in accordance with Sydney Trains rules and procedures, so that key employees in the Rail Management Centre received delayed and/or partial information and allowed the train to continue in service.
The lack of an appointed Officer in Charge of the incident site prior to the arrival of an Incident Rail Commander led to a fragmented response with no single employee having a recognised leadership role on site.
Key staff had not been trained in Rail Resource Management.
Drivers are desensitised to the wheel slip protection indicator light activations through its regular activation in response to momentary losses of adhesion. This, coupled with the inadequate warning provided by the TMS, may result in delayed reaction in response to activations that need driver intervention.
The scheduled ultrasonic tests conducted in November 2013 on the 80 lb/yd rail between Northgate and Alice Springs had been ineffective in detecting and quantifying the significant defects present at 1036.541 km and 975.244 km locations.
Contrary to the requirements of procedure IN-PRC-020, GWA had not established a list of specific locations known to have an increased likelihood of failure, such that particular attention may be applied in those locations during inspections.
The placement of the insulated rail joints adjacent to signal DYN150 was not in accordance with the ARTC engineering procedure ESC-07-01.
The practice of using a third party (the shunt planner) to facilitate communication between Network Control Officers and train drivers at the Melbourne Freight Terminal prevented an effective response to the emergency.
Track defect monitoring and reporting was not being conducted as specified in the Westrail Narrow Gauge Mainline Code of Practice, limiting the awareness of the deteriorating track condition and the need for reassessment of track operating limits.
The rail transport operator (GWA) had not maintained sufficient oversight of the activities of the rail infrastructure manager (Transfield Services), allowing the track to deteriorate to a level where trains could not be reliably run in a safe manner.
V/Line’s process for the inspection of level crossing sighting did not provide explicit instructions for the identification and removal of problem vegetation.
The Pacific National freight loading manual, and application of it, was ineffective at preventing loadshift with rod-in-coil product.
There was a breakdown in the NCO handover process used at Morisset which resulted in ASB being granted to the Protection Officer at Warnervale without the exact location of trains being properly established, signals V8 and V6 being set back to stop and blocking facilities applied in accordance with Network Rule NWT 308.
The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment.
SBR’s fatigue-management processes were ineffective in identifying the fatigue impairment experienced by the driver leading up to, and at the time of the occurrence.
The procedures in the ARTC CoP for the use and verification of a conditional proceed authority were ineffective in mitigating the risk to the effectiveness of that authority arising from human error.
The ARTC communication protocols did not provide the NCO adequate guidance with respect to standardised phraseology to ensure messages are clear and unambiguous.