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.
Pacific National’s rostering and fatigue management system used the FAID biomathematical model of fatigue to assess the fatigue risks associated with train driver rosters, applying a threshold FAID score of 80 for driver only operations and 100 for other operations. The operator had not conducted analysis to determine that train drivers working rosters according to these thresholds were sufficiently rested to conduct driving duties.
Qube’s operational procedure for train management between Moss Vale and Inner Harbour did not account for locomotive configurations that maintained locomotive dynamic braking during emergency applications. This increased the risk of the train driver avoiding the use of the emergency brake during a runaway event.
The assumptions regarding locomotive configurations that cut-out locomotive dynamic braking during emergency applications was found embedded in other rollingstock operator’s procedures with similarly configured locomotives in NSW.
Network pre-start briefings are a critical control in place to manage the risk of collisions between rail traffic and workers and machinery, and Queensland Rail had undertaken significant work to improve these processes. However, the design of the first-line assurance activities and the limited conduct of second-line and third-line assurance activities provided only limited assurance that the worksite protection aspects of the briefings were being conducted effectively.
The Queensland Network Rules and Procedures did not provide sufficient guidance for rail safety workers to ensure they used standardised rail-specific terminology when communicating safety-critical information.
There was no formal interface agreement between Queensland Rail and the Brisbane City Council to jointly identify and manage ongoing and changing safety risks at the road and rail Interface.
Queensland Rail had insufficient resources available to assess all 1,138 public level crossings at 5 yearly intervals or sooner as required by its level crossing safety Standard, with only one person qualified to conduct level crossing safety assessments.
Although Queensland Rail’s internal standard required safety assessments of each public level crossing at least every 5 years, there had been no review or assessment of the Kianawah Road and other level crossings since 2001–2002.
Contrary to the relevant Australian Standard, there was a 3.1 m gap between the tip of the lowered boom barrier and the median island on the northern side of the Kianawah Road level crossing. With the turn line markings directing traffic towards the gap, this increased the risk of road users turning right from Lindum Road and bypassing the boom barrier while it was active.
NSW Trains’ training of passenger services crew did not include periodic simulated exercises that would allow crew members to demonstrate and maintain the knowledge and skills required in an emergency.
NSW Trains’ procedures did not provide specific instructions to passenger services crew on when, how and what to communicate to passengers 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.
Contemporary Australian industry rail standards did not include requirements for ground-level access to or egress from driver's cabs in the event of a rollover.
Contemporary Australian industry rail standards did not include structural requirements for cab doors, or other performance-based requirements, that addressed the protection of train crew in the case of vehicle overturn.
NSW Trains did not have a functioning system to monitor that drivers starting their shift at Junee received and had understood distributed safety information.
NSW Trains did not have a functioning process for obtaining safety information from the ARTC web portal for its rolling stock operations within Victoria and did not routinely obtain ARTC train notices.
