Transfield did not provide oversight sufficient to identify and rectify the non-compliant work practices in the road-rail vehicle operation involved in this occurrence.
The train operator’s Route Knowledge Package did not include track layout diagrams, or specific information warning of the existence of dual-gauge turnouts where track terminated in one direction.
The configuration of the dual-gauge points assembly led to a truncated broad-gauge rail in one of the turnout directions.
When train 9501 approached signal DYN114, which was displaying a Stop indication, there was minimal indication to the network control officer that the train gauge and the selected route were incompatible.
The procedures and guidance documentation for authorising movement past signals displaying a Stop indication was ambiguous.
The process undertaken by the network control officer for issuing a Caution Order does not require validation of compatibility between the train gauge and the established route.
There was no warning indication at signal DYN114 to warn train crews that the broad-gauge rail terminated in the straight-ahead direction.
The train control system screen display provided no direct indication to the network control officer that one section of the established route was dual-gauge and another section single-gauge.
Although the operator’s rostering practices were consistent with the existing regulatory requirements, it had limited processes in place to proactively manage its flight crew rosters and ensure that fatigue risk due to restricted sleep was effectively minimised.
The manufacturer’s specified procedure for assembling and torqueing of the crankshaft/propeller flange fasteners was ineffective in ensuring resistance against subsequent joint movement in service.
Jabiru engines manufactured before July 2011 have reduced strength and reliability of the crankshaft/propeller flange joint, compared with the later design that incorporated positive location dowel pins.
The engine manufacturer’s documents with respect to the propeller mounting flange were technically inconsistent with regard to painting and torqueing procedures.
Track walking inspections were not conducted at intervals specified by V/Line’s maintenance program
V/Line's track inspection regime did not identify the degraded condition of the mechanical rail joints.
The instructions relating to the arranging of refuelling at Parkeston contained in the Pacific National train management plan and the intermodal procedures manual were inconsistent.
The on board familiarisation process did not ensure that new crew members were informed of the precautions required when working on deck while the gantry cranes were in operation.
The gantry crane in motion warning light nearest to the assistant electrician’s location was not operating and the warning sirens were not audible from his location. As a result, he was not provided with either a visual or audible warning of the crane’s movement.
There was a lack of mapping information available to assist the ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area.
The West Coast Wilderness Railway did not have a documented process of testing road-rail vehicles.
The training provided to the West Coast Wilderness Railway road-rail vehicle operators did not identify and incorporate local specific training requirements, such as operating on very steep grades and the use of radios.
