The Sydney Trains regime for auditing worksite protection arrangements was not effective in identifying emerging trends or safety critical issues when using Absolute Signal Blocking (ASB).
Differences exist in the way signallers and Protection Officers (POs) identify trains to each other.
The GWA guidance does not provide clear and unambiguous information for train crews on acceptable points approach speeds where sighting distance is reduced
The train crew had conflicting responsibilities distracting them from the safety critical task of driving. GWA did not have specific policies and procedures to define responsibilities of train crews approaching safety critical phases of operation.
Union Reef was not treated as a special location as defined in the ARA Code of Practice for the Australian Rail Network.
The ARTC’s inspection and maintenance practices were ineffective at identifying and correcting the deteriorating condition of track infrastructure exhibiting accelerated wear, such as 38A points at Spencer Junction.
A caution order instrument was used that lacked a specific requirement for train crews to check the points along their route. This requirement becomes critical under circumstances of signalling system degradation.
The Train Control System permitted the NCO to set an unviable route for the train and then displayed it as viable. The train control system alarm designed to alert the NCO to the setting of an unviable route was nullified by the absence of gauge detection.
The procedures for locomotive inspection and maintenance were not effective at identifying and addressing continuing fuel leakage problems on this type of fuel filter assembly.
The road incline on the west-side approach to the crossing increased the time required for loaded trucks to transit the crossing.
V/Line did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the rail operator in 2009.
When the crossing was last surveyed under the ALCAM program, the measurement of the road angle resulted in an overestimation of the acute road-to-rail interface angle. The implication of overestimating the acute interface angle is that sighting deficiencies may be underestimated or not identified.
There existed an inconsistency between the track speed used for crossing assessment and permitted train speeds. The ALCAM process used a train speed equal to the track line speed, whereas V/Line systems for evaluating driver behaviour permitted an exceedence of line speed by up to 10 km/h for short distances.
For eastbound road users approaching the B. McCann Road level crossing along the left-side of the road, the view to the track was restricted due to the acute road-to-rail interface. This was particularly problematic for trucks with the viewing opportunity to the left limited to the cab’s passenger-side window.
The give-way protection installed at the crossing was inconsistent with the available sighting distances on both approaches to the crossing. Sighting was affected by vegetation, embankments formed by a rail cutting and the curved road approaches.
The level crossing safety coordination processes did not involve a key stakeholder, the gypsum mine owner, who had knowledge of the changing traffic profile. The mine owner was aware of the increasing numbers of heavy vehicles using B. McCann Road since 2010 and the associated changing risk profile of the level crossing.
Gannawarra Shire did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the Shire in 2009.
Sydney Trains validation processes were not effective in detecting errors in Special Train Notice (STN) 1004 prior to the Local Possession Authority (LPA) implementation.
There were non-compliances to the repeat back provision because it was viewed as onerous under certain Local Possession Authorities (LPAs). An opportunity exists to review rule non-conformance with the implementation of LPAs.
Transfield did not have adequate systems in place to ensure workers were not adversely affected by drugs or alcohol while conducting safety related work in a remote work environment.
