STM did not require the application of all available and reasonably practicable risk controls when parking trams with respect to their location and handbrake application.
STM did not comply with its risk control in ensuring that trams were attended when parked.
STM did not follow its change management process for adopting the new hardwood chock type. Subsequently, the hardwood chock could not be applied reliably under the ‘J’ class wheel and could not restrict its movement.
A more stringent maintenance response than that for an isolated track geometry defect was not considered or implemented in accordance with ARTC’s COP. A more stringent maintenance response should have been considered given the degraded formation and the track’s rapid deterioration between 12-14 January 2016, two days prior to the derailment
The shear key was not installed in accordance with the geotechnical engineer’s specification with respect to the following:
a) It did not include a cross-drain.
b) Its width was less than the specified width.
The location did not have adequate surface drainage which likely contributed to formation degradation over time.
ARTC allowed identified track twist defects to remain in track contrary to network track geometry requirements.
Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements.
The train was loaded by approximately 10 per cent more than that recorded on the consist, it is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train.
The general condition of the rail on the west track, in the vicinity of the rail fracture, contributed to relatively frequent failures in that area.
The presence of the earlier design of yoke on wagon NGKF 35898X was not detected during preventative maintenance activities.
The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to override an initial lower-priority call.
There was no network standard that directly dealt with increased derailment risk on small-radius curves.
Track geometry through the Rushall curve was not managed in accordance with Metro Trains Melbourne (MTM) network standards. A wide-gauge ‘A’ fault was not rectified in the field despite being closed-out on the asset management system.
The network’s track geometry standard did not include any specific requirement to limit a localised lateral angular discontinuity in rail line at a mechanical joint.
The network’s track geometry standards were probably unsuitable for small-radius Broad-Gauge curves. A combination of track geometry irregularities had increased the probability of flange-climb at several locations on the small-radius Rushall curve.
The positioning of the rail lubricators at this and several other locations on the network was not consistent with Metro Trains Melbourne (MTM) guidelines and probably reduced their effectiveness.
The maintenance of rail lubricators had become less effective in the months leading up to the derailment. This work was being transferred from contractors to internal Metro Trains Melbourne (MTM) staff and the transition was not adequately managed.
Rules and procedures for detrainment do not consider a priority option of moving the train to a station or platform.
The purpose of communication between key operational people was not always clearly stated nor understood leading to misunderstandings between people.
