Absence of authority-overrun protection
The park brakes were ineffective
Unaware of forced lead function
Change of ends process is unclear
Axle bearing installation process
Unapproved practice during TWA
Implementation of risk triggered commentary driving (RTCD)
Design of the automatic warning system (AWS)
Use of event recorders to monitor driver performance
Oversight of the train driver maintenance of competency process
Inspection processes
Management of track lateral stability