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.
Key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority.
The crew of V938 detrained passengers onto the track near Kilbride without having arranged the required train protection with the ARTC Network Controller in accordance with the ARTC Network rules and procedures.
There was an identified gap in the knowledge of track maintenance personnel that was probably the result of deficiencies in training and development. In addition, network standards for the assessment of track lateral stability, including creep management, provided limited information and tools for maintenance personnel.
There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.
Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.
Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.
The inspection regime to identify rail fractures was ineffective for the condition of this track.
Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.
The procedures for measuring, assessing, and remediating rail creep in spring did not ensure creep defects were addressed in a timely manner and prior to the onset of hot weather. A creep defect identified by the spring measurements was not corrected before the derailment.
There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.
Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.
The rule describing the required driver response to a Distant signal at Caution in a two-position signalling system did not fully reflect the signalling system design principles.
The training and assessment of the driver did not ensure that he had an adequate understanding of the two-position signalling through Marshall.
The Queensland Rail network rules, procedures and safety manual provided insufficient guidance to identify the magnitude of the potential hazard from a weather event, or define the response when encountering water that had previously overtopped the track and receded or was pooled against the track formation or ballast.
The Queensland Rail General Operational Safety Manual (MD-10-107) contained insufficient guidance for rail traffic crews to ensure the timely identification and management of a potential hazard (resulting from a weather event) that might affect the safe progress of the train.
