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.
The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.
The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.
Despite a number of incidents, Pacific National did not take adequate action, before the derailment, to reduce the risk of wheel defects, especially in light of previously identified contributors such as low rim thickness.
The wheel inspection processes and systems were not effective in detecting surface damage or cracks on the R4 wheel on wagon NHIH97081 prior to the wheel failure.
Due to the curvature of the track, a wide gap existed between the platform and train at the Heyington Railway Station. There are several stations on the Melbourne metropolitan rail network where wide gaps exist between platforms and trains due to track curvature. These gaps pose a risk to passengers.
The existing standards stipulated minimum clearances between trains and platforms but did not consider the effect of the resulting gaps with respect to safe accessibility.
The train door open/close indicator on the driver’s control console was inadequate as a warning device once the traction interlock had deactivated.
As designed, the traction interlock automatically deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.
Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver.
When the AK Car was operating in Manual mode, the methods used to identify the location of a defect, and assist track staff to locate the defect could be ineffective in certain scenarios. At the derailment location, there was a consistent offset of about 58 m between the recorded location of the wide-gauge defect and its actual location due to the presence of a ‘long kilometre’.
ARTC processes for managing the condition of the rail were ineffective despite repeated recording of rail head wear by the AK Car, and local knowledge of the worn rail. The rail was worn beyond the rail condemning limits specified within the network code of practice.
The ARTC response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October.
Track patrol processes were ineffective at detecting and remedying the wide gauge defect at the derailment location. Track patrols were overly reliant on the AK Car geometry recording vehicle to trigger maintenance action on this track geometry defect.
The ARTC Local Appendix Unit North – Volume 3 did not reflect current equipment installation arrangements for E Frame at Singleton.
The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display.
The practice of pathing a following train onto the same line occupied by a preceding train, without pre-warning the driver regarding the train ahead, presented an elevated level of risk.
