Management of late-notice roster changes
Risk management associated with changing allright signal procedures for the NGR
Task design – brake pipe emergencies and penalties
Risk assessment for a rail-mounted equipment interaction incident
Recovery controls – ATP/ECPB interaction
Operating instructions – brake pipe emergencies and penalties
Fatigue management of train drivers
Inconsistencies with application of fatigue management system
The ASB rule and procedure for using an alternative route
Signaller supervision
Absence of authority-overrun protection
The park brakes were ineffective