Despite numerous occurrences of slip-slide events in the years leading up to the accident at Cleveland, Queensland Rail’s risk management processes did not precipitate a broad, cross-divisional, consideration of solutions to the issue including an investigation of the factors relating to poor wheel/rail adhesion.
The Queensland Rail internal emergency debrief following the Cleveland station collision identified issues related to working with external agencies but did not address critical communication shortfalls within train control and between train control and the staff located at the Cleveland station accident site.
The national rail occurrence standard and guidelines (ON-S1/OC-G1) do not include significant train wheel slip/slide occurrences as a notification category/type which has the potential to lead to rail safety regulators being unaware of significant and/or systemic safety issues related to wheel/rail adhesion.
The Queensland Rail driver’s manual did not explain the effects of low adhesion at the wheel/rail interface, how low adhesion is a precursor to prolonged wheel slide events and why these elements reduce the likelihood of achieving expected braking rates.
Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in precipitating appropriate safety action to the findings and recommendations of their investigations into the Beerwah SPADs in 2009 which identified wheel/rail adhesion issues.
Emergency management simulation exercises to test the preparedness of network control staff, train crew, and station customer service staff to respond cooperatively to rail safety emergencies had not been undertaken in accordance with the Queensland Rail Emergency Management Plan.
The successful management of an emergency event from a remote location is critically dependent on clear and effective communication protocols. Communications within train control, and between train control and Cleveland station, were not sufficiently coordinated and resulted in misunderstandings at the Cleveland station accident site.
Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in identifying safety issues pertinent to their fleet from rail safety occurrences in other jurisdictions involving poor wheel/rail adhesion.
Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion.
Poor wheel/rail adhesion was not recognised as a risk in any of Queensland Rail’s risk registers and therefore this risk to the safety of rail operations was not being actively managed.
Though airborne search and rescue service providers were regularly tasked to provide assistance to pilots in distress, there was limited specific guidance on the conduct of such assistance.
The mass of the two IMU or SMU class train units travelling on the Cleveland line was commonly heavier than the design specification of the buffer stop at Cleveland station. It is probable that Queensland Rail’s risk management systems did not consider this design criterion for these train configurations arriving at Cleveland station.
The Tiger Airways Australia Pty Ltd documentation and training package relating to the Avalon airspace structure and night visual approach guidance contained incorrect material and omissions that increased the risk of confusion and misunderstanding by flight crews.
The Manual of Air Traffic Services differed from the Civil Aviation Safety Regulation Part 172 Manual of Standards concerning the requirements for issuing a night visual approach to an instrument flight rules aircraft, increasing the risk of ambiguity in the application of these requirements by controllers.
Once within the level crossing there are no readily visible cues (like short range lights) to alert a driver that the level crossing protection system is operating.
There is no available refuge or escape area within the traffic island at the northbound exit of the level crossing.
The level crossing is longer than necessary. Shortening it would reduce the amount of time that a vehicle spends within the crossing and improve the visual information available to motorists when assessing their ability to clear the crossing.
The Market Street pedestrian crossing traffic lights do not effectively coordinate with the level crossing equipment. When these lights are operating, vehicles can be forced to queue through the roundabout and thus block traffic that is attempting to exit the level crossing while a train is approaching.
There was no documented procedure for assuring the separation of aircraft departing from Sydney with parachute operations at Richmond, increasing the likelihood that Sydney Terminal Control Unit controllers would have differing expectations as to their control and coordination requirements in respect of these operations.
Local and national air traffic control procedures did not prescribe the means for controllers to indicate in the air traffic control system that a parachute drop clearance had been issued.
