There are inconsistencies between Right of Way Work Instructions and the Common General Operating Rules.
SPAD Investigation Form (RS-ADL-283) used by Public Transport Services does not collect data on many of the human factor issues that would facilitate a better understanding of why SPADs are occurring.
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.
Public Transport Services have not implemented simulator training or a similar interactive system which would allow new drivers to practice, retain and apply what they have learned without the risks associated with driving trains in traffic.
Public Transport Services driver training does not adequately address the risk of distraction and areas of human performance error with respect to SPAD events.
Public Transport Services procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.
There are inconsistencies between Right of Way procedures used by platform coordinators and passenger service attendants.
Examination of RailBAM® data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, inspection of the data showed that there was a growing/trending problem with the 2L axle-box.
An examination of wheel impact (WILD) data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, running a trend analysis of WILD data clearly showed that there was a growing wheel impact problem.
All limestone bulk hopper wagons have been operated up to 15 km/h higher than speeds specified in the Train Operating Conditions Manual, when loaded above 92 t and operated on class 1 or 1C track.
The wheel bearings on train 2224, consist BT22, were only being monitored in-service by periodic inspections, roll-bys, and hot box detections. These measures were ineffective in detecting the failure of the bearing on train 2224 before it led to the derailment.
The Manildra Mill shunt locomotive did not have a CountryNet communication system installed as required by the New South Wales Rail Safety (General) Regulation 2008.
Rule ANWT 304 (ARTC) NWT 304 (RailCorp) does not stipulate that the Protection Officer must inform all persons or work groups who may be within the boundaries of a Track Occupancy Authority of its existence. This is regardless of whether or not these persons or work groups fit the definition of ‘work parties’ or ‘workers’.
The current TOA form (ANRF 002) does not allow the user to record details of protection measures enacted or whether all persons or work groups within the boundaries of the Track Occupancy Authority have been informed of its existence.
The NSW rules and procedures do not clearly address the requirements relating to protection of ‘out of service’ track infrastructure.
The communications equipment available to the Supervisor (Excavators) was inadequate to effectively communicate with the Supervisor (Track Machines) and with the drivers of the track mounted excavators between Darrine and Jaurdi.
At separate pre-work briefings, there was no discussion about train running information and site protection between the Supervisor (Excavators) and the Supervisor (Track Machines).
