There was no clear guidance within the WestNet Rail rules for train crews that defined an allowable speed associated with proceeding 'cautiously'. Had the train been travelling at a slower speed it is probable that the extent of damage caused by the derailment would have been less.
Unused bolt holes in the rail web are sufficient stress concentrators to result in the initiation and propagation of fatigue cracking, ultimately leading to the failure of the rail.
ARTC procedures for managing limit of authority over-runs by trains appear to be inconsistent with the applicable network rule as they do not mandate an immediate emergency call from the train control centre to the train crew as the first response.
There was insufficient sighting distance of the Down distant signal and insufficient distance between the Down distant signal and Down outer home signal at Gloucester to allow train 2WB3 to stop at the Down outer home signal from the permitted track speed of 70 km/h.
NSW Trains’ methods of providing safety information to passengers (including verbal safety briefings, onboard guides and signage) did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency.
NSW Trains’ methods of providing safety information to passengers (including verbal safety briefings, onboard guides and signage) did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency.
The axle bearing installation process was not sufficient to ensure the tabs on the locking plate were installed correctly.
