The Market Street pedestrian crossing traffic lights do not effectively coordinate with the level crossing equipment. When these lights are operating, vehicles can be forced to queue through the roundabout and thus block traffic that is attempting to exit the level crossing while a train is approaching.
The mass of the two IMU or SMU class train units travelling on the Cleveland line was commonly heavier than the design specification of the buffer stop at Cleveland station. It is probable that Queensland Rail’s risk management systems did not consider this design criterion for these train configurations arriving at Cleveland station.
Pacific National Bulk Rail does not provide coach/tutor drivers with sufficient training and direction as to how to perform their role.
Pacific National Bulk Rail division did not provide training on fatigue management to the driver.
Pacific National’s SPAD strategy focuses on individual crew actions and the costs of SPADs, rather than developing integrated error tolerant systems of work with regard for the broader systemic issues known to contribute to SPAD events.
Pacific National's fatigue management system is over-reliant on the use of a bio-mathematical model to predict individual fatigue risk, being based principally on rostered work hours without due consideration to higher level fatigue risk management strategies.
A review of the signage requirements for compliance with Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings indicated that the Stop Sign Ahead (W3-1) was missing on the northern side of the Brown Street level crossing.
For approaches other than the one taken by this motor vehicle driver, this level crossing did not meet the requirements of Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings.
Track inspections were not consistently conducted at intervals of not more than 96 hours, in accordance with TasRail’s standard.
The twist defect was not detected by TasRail’s inspection/monitoring systems, increasing the risk of derailment.
TasRail had not instigated proactive action to manage the elevated risks associated with ongoing track stability issues at, or near, the derailment site in accordance with their maintenance procedures.
The ARTC had not instigated proactive action to manage the increased risk of a buckling event in accordance with their procedure ETM-06-06 (Managing Track Stability – Concrete Sleepered Track) at section 1.11.5 - ‘Special Locations’.
The ARTC’s systems and operational procedures provided limited additional information or guidance to assist network control staff in identifying and assessing a potential threat to the serviceability of the infrastructure resulting from significant weather events.
West Coast Wilderness Railway had not considered all of the risks associated with the operation of road-rail vehicles on the steep railway. As a result, documented operational procedures had not been developed and locations where vehicles could be safely on/off railed had not been defined.
The wheel inspection processes prior to the failure of locomotive wheel L4 on SCT 008 were not effective in detecting surface damage or cracks
Subsurface cracks appeared to be more common on wheels made with Class BM grade steel while operating under conditions of high speed cyclic loading, such as the SCT class locomotives
There were some minor non-conformances with the level crossing signage, in particular the ‘Stop’ sign assembly and positioning of the ‘Stop’ line on the western side of the Port Flinders Causeway Road level crossing.
The method used to ultrasonically test the tail pins in-situ was not reliable and resulted in small fatigue cracks going undetected.
RailCorp’s acceptance testing regime for tail pins did not identify that the tail pins stamped BU 06 04 were below standard and, hence, not suitable for service.
Specialised Bulk Rail’s Safety Management System procedures did not provide the supervising drivers with sufficient direction as to the nature of their supervisory role.
