The system of placing protection flags on both ends of a train set does not provide a positive isolation of energy to ensure a train cannot be moved while it is being worked on.
The Skitube system for managing access to track did not detect the conflict of the rail maintenance worker under the train at the same time the train was being shunted.
VicTrack’s contractor, UGL Engineering Limited, did not provide signalling testers with specific instructions detailing the scope of work to be conducted at each stage of a project, but rather, only provided packaged isolation plans for the entire project. The absence of these instructions increased the risk of the works being incorrectly implemented.
Aurizon did not provide drivers with ready access to Queensland Rail’s procedures for driver only operations and overhead line equipment emergencies when they were operating on the Queensland Rail network. In addition, Aurizon did not have procedures for driver only operations that applied to its own network.
Aurizon did not have an effective system in place for ensuring personnel required to check the securing of unusual loads (such as empty flat racks) prior to departure had sufficient knowledge of their responsibilities, and had ready access to relevant procedures, guidance and checklists.
Aurizon’s procedures and guidance for two-driver operation during situations such as a condition affecting the network (CAN) did not facilitate the effective sharing of duties and teamwork to minimise the potential effects of degraded conditions on driver workload and fatigue.
Queensland Rail did not have any restrictions on the distance or time that controlled speed could be used as a risk control for safe train operation in situations such as a condition affecting the network (CAN). The effectiveness of controlled speed has the significant potential to deteriorate over extended time periods due to its effect on driver workload, vigilance, fatigue and risk perception.
Queensland Rail did not have procedures that required network control personnel to actively search for information about track conditions ahead of a train during situations such as a condition affecting the network (CAN), when conditions had the realistic potential to have deteriorated since the last patrol or train had run over the relevant sections.
Queensland Rail did not have an effective means of ensuring that, during situations such as a condition affecting the network (CAN), network control personnel were aware of the relevant weather monitoring systems that were unserviceable.
Sydney Trains' control of the access and egress to the project worksite did not ensure that all workers entering the worksite were identified and received an induction.
Queensland Rail did not have a procedure in place to cross-check a master circuit diagram with the existing configuration of the in-field equipment before using the diagram for safety critical work. This removed an opportunity to detect any error in master circuit diagrams.
There were track defects identified in the vicinity of the derailment site prior to the derailment. The maintenance of defects in this section of track was not successful in preventing the defects from re-occurring.
Post-incident inspection of the derailment site identified a number of factors that increased the risk of a derailment in the refuge and main line. ARTC’s maintenance activities had identified some but not all of these factors prior to the derailment.
ARTC's network rules did not provide suitable guidance to assess continued safe operation when responding to track circuit faults. Additionally, the network rules permitting signals to be passed at Stop did not require a reduction in speed when the condition of the track was unknown.
The Sydney Trains worksite briefing process did not compel a new work group to seek a worksite protection pre-work briefing when accessing an existing worksite.
The worksite protection method presented an increased risk, in that track workers might inadvertently exit the worksite, and subsequently be in the immediate vicinity of operational main line rail traffic. Sydney Trains network rules and procedures for a Track Occupancy Authority did not manage the increased risk for the chosen worksite protection method.
The network rules and procedures require communications to be clear, brief and unambiguous. Network communications by various parties in Sydney Trains were not in accordance with the principles underpinning the network rules.
Sydney Trains’ work-planning process, involving multiple work groups, did not assure the consideration of worksite safety for all tasks undertaken by each involved party over the duration of the work and when returning the rail infrastructure into service.
Pacific National's training course for the loading and securing of freight, and their verification of competency checks for inspection staff, did not include the Freight Loading Manual requirements for non-standard and modified containers.
While the Freight Loading Manual was available to customers, Pacific National did not actively advise them when they had a responsibility identified by the manual. Further, they did not have a process for ensuring that customers complied with the manual’s requirements.