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.
The Train Control System permitted the NCO to set an unviable route for the train and then displayed it as viable. The train control system alarm designed to alert the NCO to the setting of an unviable route was nullified by the absence of gauge detection.
The procedures for locomotive inspection and maintenance were not effective at identifying and addressing continuing fuel leakage problems on this type of fuel filter assembly.
The road incline on the west-side approach to the crossing increased the time required for loaded trucks to transit the crossing.
V/Line did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the rail operator in 2009.
There existed an inconsistency between the track speed used for crossing assessment and permitted train speeds. The ALCAM process used a train speed equal to the track line speed, whereas V/Line systems for evaluating driver behaviour permitted an exceedence of line speed by up to 10 km/h for short distances.
The give-way protection installed at the crossing was inconsistent with the available sighting distances on both approaches to the crossing. Sighting was affected by vegetation, embankments formed by a rail cutting and the curved road approaches.
For eastbound road users approaching the B. McCann Road level crossing along the left-side of the road, the view to the track was restricted due to the acute road-to-rail interface. This was particularly problematic for trucks with the viewing opportunity to the left limited to the cab’s passenger-side window.
When the crossing was last surveyed under the ALCAM program, the measurement of the road angle resulted in an overestimation of the acute road-to-rail interface angle. The implication of overestimating the acute interface angle is that sighting deficiencies may be underestimated or not identified.
The level crossing safety coordination processes did not involve a key stakeholder, the gypsum mine owner, who had knowledge of the changing traffic profile. The mine owner was aware of the increasing numbers of heavy vehicles using B. McCann Road since 2010 and the associated changing risk profile of the level crossing.
Gannawarra Shire did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the Shire in 2009.
Sydney Trains validation processes were not effective in detecting errors in Special Train Notice (STN) 1004 prior to the Local Possession Authority (LPA) implementation.
There were non-compliances to the repeat back provision because it was viewed as onerous under certain Local Possession Authorities (LPAs). An opportunity exists to review rule non-conformance with the implementation of LPAs.
Transfield did not have adequate systems in place to ensure workers were not adversely affected by drugs or alcohol while conducting safety related work in a remote work environment.
The maintenance regime for Hino TS63 was inadequate and did not account for the accelerated wear and tear on the vehicle when used as a road-rail vehicle.
Transfield did not provide oversight sufficient to identify and rectify the non-compliant work practices in the road-rail vehicle operation involved in this occurrence.
The absence of a national standard that addresses the design, fitment and maintenance of rail guidance equipment and the safety performance for road-rail vehicles while on-rail, increases the risks associated with operating road-rail vehicles.
Transfield’s training regime did not ensure that the track workers involved in this occurrence were trained in new or updated work practices relating to road-rail vehicle operations. Similarly, relevant amended procedures, safety bulletins and alerts had not been effectively promulgated to these employees.
There was no warning indication at signal DYN114 to warn train crews that the broad-gauge rail terminated in the straight-ahead direction.
The process undertaken by the network control officer for issuing a Caution Order does not require validation of compatibility between the train gauge and the established route.
