The ultrasonic testing regime was not effective in consistently identifying corrosion and wasting of the rail web at unsealed level crossings.
GWA had no documented system in place to assess the suitability of second-hand components for re-use.
After re-railing the track, permitted train speed was increased without due consideration of the effects of cyclic track irregularities on the dynamic performance of the WOE class wagon.
The frequency of driver reporting and locomotive cab rides by track inspectors had been insufficient for identifying rough track through the derailment site.
When travelling at speeds near 90 km/h on track having particular track irregularities, the WOE class wagons appear to be susceptible to harmonic oscillations of sufficient magnitude to produce wheel unloading, flange climb and derailment.
The loss of brake pipe integrity during the derailment event did not result in the train brakes automatically activating.
A register for recording ‘special locations’ in accordance with the ARTC Engineering (Track & Civil) Code of Practice - Section 10 – Flooding, had not been established to manage track infrastructure prone to flood damage.
The ARTC’s processes for developing and implementing changes to operational procedures as a result of incident investigation findings were ineffective at mitigating the risk of future similar incidents.
The ARTC did not have a comprehensive system in place to identify and actively manage risks associated with severe weather events that were likely to affect the safety of their rail network.
Genesee & Wyoming Australia had no procedure in place to verify (either in total or by random selection) that the nature or condition of freight provided by their customers, complied with their Standard Condition of Carriage.
Rule NWT 308 Absolute Signal Blocking and procedure NPR703 Using Absolute Signal Blocking did not provide any guidance on acceptable methods for determining the location of rail traffic in the section or confirming the clearance of rail traffic past a proposed work location.
Not all major infrastructure was marked on the ATRICS screens for the North Shore panel.
There were no forms or checklists to provide practical guidance for completing the steps required to implement Absolute Signal Blocking (ASB) or to provide an auditable record of the process.
Differences exist in the way signallers and Protection Officers (POs) identify trains to each other.
The Sydney Trains regime for auditing worksite protection arrangements was not effective in identifying emerging trends or safety critical issues when using Absolute Signal Blocking (ASB).
The GWA guidance does not provide clear and unambiguous information for train crews on acceptable points approach speeds where sighting distance is reduced
The train crew had conflicting responsibilities distracting them from the safety critical task of driving. GWA did not have specific policies and procedures to define responsibilities of train crews approaching safety critical phases of operation.
Union Reef was not treated as a special location as defined in the ARA Code of Practice for the Australian Rail Network.
The ARTC’s inspection and maintenance practices were ineffective at identifying and correcting the deteriorating condition of track infrastructure exhibiting accelerated wear, such as 38A points at Spencer Junction.
A caution order instrument was used that lacked a specific requirement for train crews to check the points along their route. This requirement becomes critical under circumstances of signalling system degradation.
