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.
The NSW rules and procedures do not clearly address the requirements relating to protection of ‘out of service’ track infrastructure.
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 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).
The voltage of signal JE02 was below the ARTC standard for the type of globe installed.
There was no RailCorp instruction that specifically referred to the need for train crew to prioritise tasks at safety critical locations or at times when workload is high.
The Microlok signalling program design does not meet the requirements of ARTC signalling standard SCP23 ‘Design of Microlok Interlockings’ in regard to the logging of internal bits that initiate flashing, pulsing or toggled outputs.
The ARTC does not have a check list available for network controllers to assist in identifying risks associated with the verbal authorisation of train movements for an integrated yard.
The documentation and quality control processes used by the South Improvement Alliance for the Cootamundra re-signalling project were not sufficiently robust, in particular, the closing out of identified design issues was inadequate.
Where a design involves complex signalling arrangements, it may be beneficial to involve the designing engineer during the final onsite field testing phase as they have the best understanding of the interlocking principles. This places them in a strong position to identify any design omissions or deficiencies that may not have been evident during earlier phases of a project.
