It was possible that at times throughout the Network Control Officer’s roster, fatigue levels were conducive to performance degradation.
The ARTC form ANRF-002 (Track Occupancy Authority) was deficient as there was no provision to record critical information regarding the location and type of worksite. Consequently, both the Protection Officer and Network Control Officer incorrectly concluded that the train had passed beyond the limits of the worksite.
Some ARTC maintenance contractors were using non-authorised reproductions of the ARTC’s Track Occupancy Authority form.
New Section Closing and Opening Authority Telegrams (SCAO) were not completed by the train controller and the Supervisor (Track Machines) for each closing and opening of the track in accordance with WestNet Rule 199.
The current ARTC definition of restricted speed requires considerable judgement on the part of train drivers.
Train drivers receive no formal training with respect to understanding severe weather events, the associated derailment risk and mitigation strategies.
Double stacked container wagons are at particular risk of wind induced roll-over. This is a direct relationship of exposed side area, and was therefore probably exacerbated by out of gauge/high loads on some wagons with a large surface area exposed to the gust front.
There was no documented evidence that Pacific National actively manages the risk of looseness and fretting damage to bearing components
Public Transport Services do not have a formal fatigue policy/procedure.
Public Transport Services driver training does not adequately address the risk of distraction and areas of human performance error with respect to SPAD events.
There are inconsistencies between Right of Way procedures used by platform coordinators and passenger service attendants.
There are inconsistencies between Right of Way Work Instructions and the Common General Operating Rules.
Public Transport Services have not implemented simulator training or a similar interactive system which would allow new drivers to practice, retain and apply what they have learned without the risks associated with driving trains in traffic.
Public Transport Services procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.
SPAD Investigation Form (RS-ADL-283) used by Public Transport Services does not collect data on many of the human factor issues that would facilitate a better understanding of why SPADs are occurring.
As a defence against driver error Public Transport Services provide their railcars with a vigilance system comprising a deadman’s control and an Automatic Warning System. However, the current system does not protect against ‘Starting against Signal’ SPAD events as occurred at Adelaide Station.
An examination of wheel impact (WILD) data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, running a trend analysis of WILD data clearly showed that there was a growing wheel impact problem.
Examination of RailBAM® data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, inspection of the data showed that there was a growing/trending problem with the 2L axle-box.
All limestone bulk hopper wagons have been operated up to 15 km/h higher than speeds specified in the Train Operating Conditions Manual, when loaded above 92 t and operated on class 1 or 1C track.
