Although Queensland Rail’s internal standard required safety assessments of each public level crossing at least every 5 years, there had been no review or assessment of the Kianawah Road and other level crossings since 2001–2002.
Contrary to the relevant Australian Standard, there was a 3.1 m gap between the tip of the lowered boom barrier and the median island on the northern side of the Kianawah Road level crossing. With the turn line markings directing traffic towards the gap, this increased the risk of road users turning right from Lindum Road and bypassing the boom barrier while it was active.
NSW Trains’ training of passenger services crew did not include periodic simulated exercises that would allow crew members to demonstrate and maintain the knowledge and skills required in an emergency.
NSW Trains’ procedures did not provide specific instructions to passenger services crew on when, how and what to communicate to passengers in an emergency.
NSW Trains’ methods of providing safety information to passengers (including verbal safety briefings, onboard guides and signage) did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency.
Contemporary Australian industry rail standards did not include requirements for ground-level access to or egress from driver's cabs in the event of a rollover.
Contemporary Australian industry rail standards did not include structural requirements for cab doors, or other performance-based requirements, that addressed the protection of train crew in the case of vehicle overturn.
NSW Trains did not have a functioning system to monitor that drivers starting their shift at Junee received and had understood distributed safety information.
NSW Trains did not have a functioning process for obtaining safety information from the ARTC web portal for its rolling stock operations within Victoria and did not routinely obtain ARTC train notices.
ARTC distribution of safety information by train notice was sub-optimal. There was scope to improve reliability of safety information distribution and to consider opportunities for operators in Victoria (and SA and WA) to receive direct distribution of train notices for their operations on the ARTC network.
For the establishment of train working arrangements that deviated from ARTC network rules, ActivateRail did not implement processes to ensure its contributions were consistent with the risk management procedures of the accredited rail infrastructure manager (ARTC) and Australian risk management standards.
For the establishment of train working arrangements that deviated from ARTC network rules, ARTC stakeholder engagement did not support its management of the safety risks to network users and the development of agreed risk controls.
For the establishment of train working arrangements that deviated from ARTC network rules, ARTC risk management and oversight processes resulted in a risk management plan that was limited in context, scope and risk identification and risk controls that had significant weaknesses.
For the routing of trains through Wallan Loop on 20 February, ARTC processes did not result in its effective engagement with network users that would be affected by this change.
NSW Trains did not have systems in place to achieve outcomes in emergency response training consistent with its competency framework for passenger services crew.
ARTC could not reliably determine the risk of flooding along the Telarah to Acacia Ridge corridor or the risks associated with inadequate capacity cross drainage systems.
Although ARTC had procedures in place for monitoring and responding to extreme weather events, the process had significant limitations including:
The weather alerts issued by the EWN did not reliably reflect the data and frequency of ARTC’s extreme weather monitoring procedure or the service agreement. This and the services ARTC believed were included in the service agreement likely impacted the expectations of ARTC users who relied on these warnings to inform their response.
