V/Line inspection regime did not identify that the interface between the unsealed road and Barwon Terrace level crossing was a safety risk. Inspections did not extend to the routine review of any changing road conditions that may heighten risk.
At Upper Ferntree Gully (and some other parts of the MTM network), the issuing of a caution order did not require validation by a second person.
Rules and procedures associated with managing trains between Bayswater and Upper Ferntree Gully were inconsistently applied and gaps in the recording protocols at Ringwood probably impacted the effectiveness of the administrative systems.
The automatic warning system (AWS) provided the same audible alarm and visual indication to a driver on the approach to all restricted indications. The potential for habituation, and the absence of a higher priority alert when approaching a signal displaying a red aspect, reduced the effectiveness of the AWS to prevent signals passed at danger (SPADs). This placed substantial reliance on procedural or administrative controls to prevent SPADs, which are fundamentally limited in their usefulness.
The signal passed at danger (SPAD) alarm for CS025 did not alert the network control officer when train TE43 passed the signal at stop. This was due to inherent constraints of the universal traffic control system, which was not considered in the way Queensland Rail managed the risk of SPADs.
Response by Queensland Rail
On 11 April 2025, Queensland Rail (QR) acknowledged that there were known circumstances in which Universal Traffic Control (UTC) may not generate a SPAD alarm at all signal locations on the QR Network.
ARTC’s systems for management of track lateral stability did not lead to identification of the location as a special location potentially vulnerable to track instability.
The South Australian Passenger Transport Authority approved a package of inspection and test plan procedures that did not specify any requirement for tests to verify and validate the safety integrity of the altered level crossing control circuits. The effectiveness of inspection and test plan procedure to control risk and provide assurance the signalling system functioned safety for trains operating on the ARTC network relied solely on the methodology adopted by the subcontracted signal team on the day.
Sydney Trains Security Control Centre Standard Operating Procedure contained conflicting instructions on incident response, which were not aligned with the Sydney Trains Network Incident Management Plan (NIMP).
Sydney Trains Security Control Centre Operator was not alerted to tampering of the cameras at Kembla Grange Station that monitored the West Dapto Road Level crossing.
The risk assessments conducted by Southern Shorthaul Railroad (SSR) for shunting and banking operations did not include consultation consisting of effective and meaningful engagement with all relevant stakeholders. This increased the potential that risks could be missed during the risk assessment process.
Southern Shorthaul Railroad's (SSR's) emergency response procedures did not include requirements for banking locomotive operations.
Southern Shorthaul Railroad's (SSR's) training and assessment did not include coupler functionality and the process to ensure correct coupling had occurred. Further, an underpinning procedure for the stretch test (effectively coupled) process did not exist.
There was probably no independent check of the isolation arrangements installed on the night of 29 November. An earlier internal audit of the project also reported instances of testers in charge checking their own work.
Metro Trains Melbourne standards and procedures did not specifically address requirements associated with fuse removal and securement in safety critical scenarios.
Changed level crossing isolation arrangements were not effectively reflected in program documentation, nor effectively disseminated to all those potentially affected. An earlier internal audit of the project also identified instances of scope changes not being documented.
Arc Infrastructure’s procedures included no requirement for a network control officer (NCO) to make an emergency call and advise potentially ‘at risk’ trains that another nearby train had overrun its limit of authority.
The Arc Infrastructure processes for the management of rail traffic overrunning its limits of authority were reliant on the immediate actions of the rail traffic crew and did not explicitly require immediate actions from the network control officer (NCO). This situation increased the risk of driver completely missed signal passed at danger (SPAD) events, particularly in cases where the rail traffic crew’s awareness or capacity was potentially compromised.
The Arc Infrastructure practice of pathing a following train up to the same section of track occupied by a stopped train, coupled with no requirement for the network control officer (NCO) to communicate and confirm rail traffic crews were aware when approaching another stopped train, increased risk.
Pacific National had limited controls for managing the risk of signals passed at danger during driver only operations, including incidents associated with driver fatigue. The safety system relied on a single driver correctly observing and responding to signals at all times, including during the window of the circadian low (when fatigue risk is greatest).
Pacific National's fatigue management procedures required train drivers to not work if they felt fatigued. This requirement primarily relied on drivers self-reporting if they felt fatigued, and there was no proactive assurance that drivers had obtained adequate sleep, including for higher fatigue risk situations. Self-reporting mechanisms were very seldom utilised and Pacific National had not conducted surveys or used other audit mechanisms or processes to identify any perceived or actual barriers to drivers self-identifying fatigue.
