V/Line did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the rail operator in 2009.
There existed an inconsistency between the track speed used for crossing assessment and permitted train speeds. The ALCAM process used a train speed equal to the track line speed, whereas V/Line systems for evaluating driver behaviour permitted an exceedence of line speed by up to 10 km/h for short distances.
When the crossing was last surveyed under the ALCAM program, the measurement of the road angle resulted in an overestimation of the acute road-to-rail interface angle. The implication of overestimating the acute interface angle is that sighting deficiencies may be underestimated or not identified.
The level crossing safety coordination processes did not involve a key stakeholder, the gypsum mine owner, who had knowledge of the changing traffic profile. The mine owner was aware of the increasing numbers of heavy vehicles using B. McCann Road since 2010 and the associated changing risk profile of the level crossing.
Gannawarra Shire did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the Shire in 2009.
There were non-compliances to the repeat back provision because it was viewed as onerous under certain Local Possession Authorities (LPAs). An opportunity exists to review rule non-conformance with the implementation of LPAs.
Sydney Trains validation processes were not effective in detecting errors in Special Train Notice (STN) 1004 prior to the Local Possession Authority (LPA) implementation.
Transfield did not have adequate systems in place to ensure workers were not adversely affected by drugs or alcohol while conducting safety related work in a remote work environment.
Transfield did not provide oversight sufficient to identify and rectify the non-compliant work practices in the road-rail vehicle operation involved in this occurrence.
Transfield’s training regime did not ensure that the track workers involved in this occurrence were trained in new or updated work practices relating to road-rail vehicle operations. Similarly, relevant amended procedures, safety bulletins and alerts had not been effectively promulgated to these employees.
The absence of a national standard that addresses the design, fitment and maintenance of rail guidance equipment and the safety performance for road-rail vehicles while on-rail, increases the risks associated with operating road-rail vehicles.
The maintenance regime for Hino TS63 was inadequate and did not account for the accelerated wear and tear on the vehicle when used as a road-rail vehicle.
The process undertaken by the network control officer for issuing a Caution Order does not require validation of compatibility between the train gauge and the established route.
The configuration of the dual-gauge points assembly led to a truncated broad-gauge rail in one of the turnout directions.
There was no warning indication at signal DYN114 to warn train crews that the broad-gauge rail terminated in the straight-ahead direction.
The procedures and guidance documentation for authorising movement past signals displaying a Stop indication was ambiguous.
The train operator’s Route Knowledge Package did not include track layout diagrams, or specific information warning of the existence of dual-gauge turnouts where track terminated in one direction.
When train 9501 approached signal DYN114, which was displaying a Stop indication, there was minimal indication to the network control officer that the train gauge and the selected route were incompatible.
The train control system screen display provided no direct indication to the network control officer that one section of the established route was dual-gauge and another section single-gauge.
V/Line's track inspection regime did not identify the degraded condition of the mechanical rail joints.
