Drivers are desensitised to the wheel slip protection indicator light activations through its regular activation in response to momentary losses of adhesion. This, coupled with the inadequate warning provided by the TMS, may result in delayed reaction in response to activations that need driver intervention.
Reporting and communications were not carried out in accordance with Sydney Trains rules and procedures, so that key employees in the Rail Management Centre received delayed and/or partial information and allowed the train to continue in service.
Key staff had not been trained in Rail Resource Management.
The lack of an appointed Officer in Charge of the incident site prior to the arrival of an Incident Rail Commander led to a fragmented response with no single employee having a recognised leadership role on site.
The scheduled ultrasonic tests conducted in November 2013 on the 80 lb/yd rail between Northgate and Alice Springs had been ineffective in detecting and quantifying the significant defects present at 1036.541 km and 975.244 km locations.
Contrary to the requirements of procedure IN-PRC-020, GWA had not established a list of specific locations known to have an increased likelihood of failure, such that particular attention may be applied in those locations during inspections.
The practice of using a third party (the shunt planner) to facilitate communication between Network Control Officers and train drivers at the Melbourne Freight Terminal prevented an effective response to the emergency.
The placement of the insulated rail joints adjacent to signal DYN150 was not in accordance with the ARTC engineering procedure ESC-07-01.
Track defect monitoring and reporting was not being conducted as specified in the Westrail Narrow Gauge Mainline Code of Practice, limiting the awareness of the deteriorating track condition and the need for reassessment of track operating limits.
The rail transport operator (GWA) had not maintained sufficient oversight of the activities of the rail infrastructure manager (Transfield Services), allowing the track to deteriorate to a level where trains could not be reliably run in a safe manner.
V/Line’s process for the inspection of level crossing sighting did not provide explicit instructions for the identification and removal of problem vegetation.
The Pacific National freight loading manual, and application of it, was ineffective at preventing load
shift with rod-in-coil product.
There was a breakdown in the NCO handover process used at Morisset which resulted in ASB being granted to the Protection Officer at Warnervale without the exact location of trains being properly established, signals V8 and V6 being set back to stop and blocking facilities applied in accordance with Network Rule NWT 308.
The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment.
The ARTC communication protocols did not provide the NCO adequate guidance with respect to standardised phraseology to ensure messages are clear and unambiguous.
The procedures in the ARTC CoP for the use and verification of a conditional proceed authority were ineffective in mitigating the risk to the effectiveness of that authority arising from human error.
SBR’s fatigue-management processes were ineffective in identifying the fatigue impairment experienced by the driver leading up to, and at the time of the occurrence.
There was no Track Stability Management Plan in place for the section of track where the buckle developed – as was required by the ARTC’s CoP.
V/Line’s organisational processes for responding to and rectifying rail creep defects did not ensure that all such defects were addressed in a timely way.
The VCA type 37 turnout design and V/Line’s provisional type approval process did not fully identify the subtle design changes inherent with the VCA type 37 turnout in determining testing, commissioning and validation needs.
