ARTC procedures for managing limit of authority over-runs by trains appear to be inconsistent with the applicable network rule as they do not mandate an immediate emergency call from the train control centre to the train crew as the first response.
There was insufficient sighting distance of the Down distant signal and insufficient distance between the Down distant signal and Down outer home signal at Gloucester to allow train 2WB3 to stop at the Down outer home signal from the permitted track speed of 70 km/h.
The ATSB recommends that Eastern Air Link address the safety issue, through provision of guidance and training to flight crew concerning the safest option in the selection of an approach method when weather conditions are marginal for the conduct of a visual approach.
The Australian Transport Safety Bureau recommends that NSW Trains undertake further work to improve the methods used to provide safety information to ensure that passengers are given a reasonable opportunity to gain knowledge of what they may be required to do in the event of an emergency.