There were no formalised processes for a driver-in-training to record their experience in learning a route, or to document feedback related to their performance, which could be used by supervising drivers or assessors to assist in mentoring them.
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.
Worker competency procedures were deficient in providing a structured program for the development of route knowledge by the driver-in-training.
The rules and procedures governing the issue of a Controlled Signal Block did not require or provide for coordination between network control officers when the Controlled Signal Block affects more than one controller’s area of responsibility.
AK Car defect exceedence reports produced on 4 February 2011 did not include fields to record the date and time of follow-up field inspections and to show that these inspections and assessment of defects were completed in accordance with the ARTC Track and Civil Code of Practice.
The urgent and priority category defects detected by the AK Car on 4 February 2011 that were located within a 20 m track section were inadequately assessed and controlled in accordance with the ARTC Track and Civil Code of Practice.
The warning systems in place to alert GWA staff as to the severity of a flood event at the Edith River Rail Bridge were ineffective.
GWA policies, procedures and training had little if any guidance for employees quantifying the duration, consequential dangers and responses to severe weather events.
The quality assurance processes used in the acceptance of the Goddards crossing loop project were not sufficiently robust to mitigate the risk of track construction inadequacies.
It was possible that at times throughout the Network Control Officer’s roster, fatigue levels were conducive to performance degradation.
The track workers were not provided with sufficient training (competency based or structured on-job training) in relation to the hazards and required protections for working under the authority in place at Newbridge on 5 May 2010.
The ARTC procedure ANPR-701 (Using a Track Occupancy Authority) was inconsistent in that it did not allow for a scenario that would otherwise be permitted, and intended, under rule ANWT-304 (Track Occupancy Authority).
Some ARTC maintenance contractors were using non-authorised reproductions of the ARTC’s Track Occupancy Authority form.
The ARTC form ANRF-002 (Track Occupancy Authority) was deficient as there was no provision to record critical information regarding the location and type of worksite. Consequently, both the Protection Officer and Network Control Officer incorrectly concluded that the train had passed beyond the limits of the worksite.
New Section Closing and Opening Authority Telegrams (SCAO) were not completed by the train controller and the Supervisor (Track Machines) for each closing and opening of the track in accordance with WestNet Rule 199.
The current ARTC definition of restricted speed requires considerable judgement on the part of train drivers.
Train drivers receive no formal training with respect to understanding severe weather events, the associated derailment risk and mitigation strategies.
Double stacked container wagons are at particular risk of wind induced roll-over. This is a direct relationship of exposed side area, and was therefore probably exacerbated by out of gauge/high loads on some wagons with a large surface area exposed to the gust front.
There was no documented evidence that Pacific National actively manages the risk of looseness and fretting damage to bearing components
As a defence against driver error Public Transport Services provide their railcars with a vigilance system comprising a deadman’s control and an Automatic Warning System. However, the current system does not protect against ‘Starting against Signal’ SPAD events as occurred at Adelaide Station.
