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.
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 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.
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.
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.
It was possible that at times throughout the Network Control Officer’s roster, fatigue levels were conducive to performance degradation.
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).
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.
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.
Train drivers receive no formal training with respect to understanding severe weather events, the associated derailment risk and mitigation strategies.
There was no documented evidence that Pacific National actively manages the risk of looseness and fretting damage to bearing components
Public Transport Services driver training does not adequately address the risk of distraction and areas of human performance error with respect to SPAD events.
There are inconsistencies between Right of Way Work Instructions and the Common General Operating Rules.
Public Transport Services do not have a formal fatigue policy/procedure.
There are inconsistencies between Right of Way procedures used by platform coordinators and passenger service attendants.
Public Transport Services procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.
