There was no warning indication at signal DYN114 to warn train crews that the broad-gauge rail terminated in the straight-ahead direction.
The configuration of the dual-gauge points assembly led to a truncated broad-gauge rail in one of the turnout directions.
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.
The procedures and guidance documentation for authorising movement past signals displaying a Stop indication was ambiguous.
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.
Track walking inspections were not conducted at intervals specified by V/Line’s maintenance program
The instructions relating to the arranging of refuelling at Parkeston contained in the Pacific National train management plan and the intermodal procedures manual were inconsistent.
The training provided to the West Coast Wilderness Railway road-rail vehicle operators did not identify and incorporate local specific training requirements, such as operating on very steep grades and the use of radios.
Rinadeena Station was the only emergency meeting point between Queenstown and Strahan and the only road access point on the rack between Halls Creek and Dubbil Barril. However, the Rinadeena Station radio was not maintained in a serviceable state at all times.
The West Coast Wilderness Railway did not have documented radio communication procedures and their staff were not trained in the use of radios. As a result, radio protocols were not formalised and communications were ad hoc and casual in nature.
West Coast Wilderness Railway had not developed and implemented a specification for the design, fitment and safety performance of road-rail vehicle rail guidance equipment.
The West Coast Wilderness Railway did not have a documented process of testing road-rail vehicles.
The Genesee and Wyoming Australia safety management system procedures did not provide supervising and trainee drivers with sufficient guidance or direction as to the extent of their supervisory or permitted driving roles.
The ATSB investigation was unable to substantiate the reported observations of the train crew without having an independent source of data, such as forward facing video on train 5BM7.
On the southern approach to the level crossing, the Stop Sign Ahead (W3-1) warning sign was not located in accordance with the requirements of AS 1742.7-2007 standard.
The boundary fence between the railway maintenance access track and Gallagher Road had been removed. As a result, over time and with regular use, the false perception that the maintenance access track was part of Gallagher Road was created and reinforced.
Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion.
The national rail occurrence standard and guidelines (ON-S1/OC-G1) do not include significant train wheel slip/slide occurrences as a notification category/type which has the potential to lead to rail safety regulators being unaware of significant and/or systemic safety issues related to wheel/rail adhesion.