Despite numerous occurrences of slip-slide events in the years leading up to the accident at Cleveland, Queensland Rail’s risk management processes did not precipitate a broad, cross-divisional, consideration of solutions to the issue including an investigation of the factors relating to poor wheel/rail adhesion.
Emergency management simulation exercises to test the preparedness of network control staff, train crew, and station customer service staff to respond cooperatively to rail safety emergencies had not been undertaken in accordance with the Queensland Rail Emergency Management Plan.
Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion.
The national rail occurrence standard and guidelines (ON-S1/OC-G1) do not include significant train wheel slip/slide occurrences as a notification category/type which has the potential to lead to rail safety regulators being unaware of significant and/or systemic safety issues related to wheel/rail adhesion.
Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in identifying safety issues pertinent to their fleet from rail safety occurrences in other jurisdictions involving poor wheel/rail adhesion.
The successful management of an emergency event from a remote location is critically dependent on clear and effective communication protocols. Communications within train control, and between train control and Cleveland station, were not sufficiently coordinated and resulted in misunderstandings at the Cleveland station accident site.
The level crossing is longer than necessary. Shortening it would reduce the amount of time that a vehicle spends within the crossing and improve the visual information available to motorists when assessing their ability to clear the crossing.
The mass of the two IMU or SMU class train units travelling on the Cleveland line was commonly heavier than the design specification of the buffer stop at Cleveland station. It is probable that Queensland Rail’s risk management systems did not consider this design criterion for these train configurations arriving at Cleveland station.
There is no available refuge or escape area within the traffic island at the northbound exit of the level crossing.
The Market Street pedestrian crossing traffic lights do not effectively coordinate with the level crossing equipment. When these lights are operating, vehicles can be forced to queue through the roundabout and thus block traffic that is attempting to exit the level crossing while a train is approaching.
Once within the level crossing there are no readily visible cues (like short range lights) to alert a driver that the level crossing protection system is operating.
Pacific National Bulk Rail does not provide coach/tutor drivers with sufficient training and direction as to how to perform their role.
Pacific National’s SPAD strategy focuses on individual crew actions and the costs of SPADs, rather than developing integrated error tolerant systems of work with regard for the broader systemic issues known to contribute to SPAD events.
Pacific National's fatigue management system is over-reliant on the use of a bio-mathematical model to predict individual fatigue risk, being based principally on rostered work hours without due consideration to higher level fatigue risk management strategies.
Pacific National Bulk Rail division did not provide training on fatigue management to the driver.
For approaches other than the one taken by this motor vehicle driver, this level crossing did not meet the requirements of Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings.
A review of the signage requirements for compliance with Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings indicated that the Stop Sign Ahead (W3-1) was missing on the northern side of the Brown Street level crossing.
The twist defect was not detected by TasRail’s inspection/monitoring systems, increasing the risk of derailment.
Track inspections were not consistently conducted at intervals of not more than 96 hours, in accordance with TasRail’s standard.
TasRail had not instigated proactive action to manage the elevated risks associated with ongoing track stability issues at, or near, the derailment site in accordance with their maintenance procedures.
