The absence of a national standard that addresses the design, fitment and maintenance of rail guidance equipment and the safety performance for road-rail vehicles while on-rail, increases the risks associated with operating road-rail vehicles.
The maintenance regime for Hino TS63 was inadequate and did not account for the accelerated wear and tear on the vehicle when used as a road-rail vehicle.
Transfield did not provide oversight sufficient to identify and rectify the non-compliant work practices in the road-rail vehicle operation involved in this occurrence.
Transfield’s training regime did not ensure that the track workers involved in this occurrence were trained in new or updated work practices relating to road-rail vehicle operations. Similarly, relevant amended procedures, safety bulletins and alerts had not been effectively promulgated to these employees.
When train 9501 approached signal DYN114, which was displaying a Stop indication, there was minimal indication to the network control officer that the train gauge and the selected route were incompatible.
The process undertaken by the network control officer for issuing a Caution Order does not require validation of compatibility between the train gauge and the established route.
There was no warning indication at signal DYN114 to warn train crews that the broad-gauge rail terminated in the straight-ahead direction.
The configuration of the dual-gauge points assembly led to a truncated broad-gauge rail in one of the turnout directions.
The procedures and guidance documentation for authorising movement past signals displaying a Stop indication was ambiguous.
The train operator’s Route Knowledge Package did not include track layout diagrams, or specific information warning of the existence of dual-gauge turnouts where track terminated in one direction.
The train control system screen display provided no direct indication to the network control officer that one section of the established route was dual-gauge and another section single-gauge.
Track walking inspections were not conducted at intervals specified by V/Line’s maintenance program
V/Line's track inspection regime did not identify the degraded condition of the mechanical rail joints.
The instructions relating to the arranging of refuelling at Parkeston contained in the Pacific National train management plan and the intermodal procedures manual were inconsistent.
West Coast Wilderness Railway had not developed and implemented a specification for the design, fitment and safety performance of road-rail vehicle rail guidance equipment.
The training provided to the West Coast Wilderness Railway road-rail vehicle operators did not identify and incorporate local specific training requirements, such as operating on very steep grades and the use of radios.
Rinadeena Station was the only emergency meeting point between Queenstown and Strahan and the only road access point on the rack between Halls Creek and Dubbil Barril. However, the Rinadeena Station radio was not maintained in a serviceable state at all times.
The West Coast Wilderness Railway did not have documented radio communication procedures and their staff were not trained in the use of radios. As a result, radio protocols were not formalised and communications were ad hoc and casual in nature.
The West Coast Wilderness Railway did not have a documented process of testing road-rail vehicles.
The Genesee and Wyoming Australia safety management system procedures did not provide supervising and trainee drivers with sufficient guidance or direction as to the extent of their supervisory or permitted driving roles.
