The TasRail cement loading facility at Railton had a downhill grade to the main line, and no devices to protect against a runaway.
Loss of adhesion leading to increased stopping distance was not recognised as a risk source for any type of collision in V/Line’s risk registers.
The processes involved in train preparation did not ensure a required minimum amount of sand in sand boxes.
Maintenance of the VLocity sander units did not include testing of sand discharge flow rates (or some other process) to confirm performance. Without performance checks over time, deficiencies could not be identified and addressed.
There was no suitable assessment of the performance of sanders on the VLocity three-car set against defined acceptance criteria for improved braking performance in low adhesion conditions.
The location of sanding nozzles (for braking) behind the wheels of the lead bogie was inconsistent with design practice existing at the time of the collision and was probably a recurring factor in diminished sander effectiveness on VLocity trains.
Safety controls were ineffective in mitigating against a train arriving at Ballarat Railway Station travelling at excessive speed and being unable to stop before colliding with the crossing gates closed against rail traffic.
Queensland Rail’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes.
Queensland Rail's process for the installation of signal aspect indicators (SAIs) did not provide sufficient detail to ensure consistent and conspicuous placement of SAIs at station platforms. This problem, combined with an SAI’s non-salient indication when the platform departure signal displayed a stop indication, increased the risk that an SAI would not be correctly perceived by a train guard.
Limitations in Queensland Rail’s application of risk management and change management processes relevant to the introduction of the new generation rollingstock (NGR) increased the risk of a start against signal SPAD (signals passed at danger).
BHP's fatigue management processes required its train drivers to be rostered on 7 12-hour shifts, followed by a 24-hour break and then 7 12-hour shifts, with the roster pattern commencing at a wide variety of times of day. Such roster patterns were conducive to result in cumulative sleep restriction and levels of fatigue likely to adversely influence performance on a significant proportion of occasions, and BHP had limited processes in place to ensure that drivers actually obtained sufficient sleep when working these roster patterns.
The automatic train protection (ATP) and electronically controlled pneumatic braking (ECPB) systems on BHP’s trains could not interface to dump brake pipe pressure if an ECPB emergency or penalty brake application became ineffective in arresting an uncommanded train movement.
Although operating instructions OI 17-11 (5 April 2017) and then OI 18-72 (3 November 2018) contained a safety-critical action (to apply the automatic brake handle to the pneumatic emergency position), BHP did not clearly communicate the importance and reasons for the safety-critical action to drivers, reducing the potential for the drivers to correctly recall this procedural action.
The task of responding to brake pipe emergencies or penalties relied extensively on a driver’s memory, with limited processes in place to facilitate or cross-check a driver’s performance to ensure all safety-critical actions were completed.
Although BHP’s risk assessment for a rail-mounted equipment interaction incident identified numerous causes and critical controls for such an incident, it was broad in scope and had limited focus on the causes and critical controls for a train runaway event. In addition, the risk assessment did not include the procedure for responding to brake pipe emergencies and penalties as a critical control and BHP’s material risk control assessments (MRCAs) did not test the effectiveness of this procedural control for preventing an uncommanded movement of a train during main line operations.
There were inconsistences with Sydney Trains’ application of their fatigue management system, in particular the the use of a bio-mathematical model to predict individual fatigue risk. (Safety issue)
Sydney Trains did not provide supervision at Granville signal box to ensure there was adequate coverage on both signalling panels. (Safety issue)
The ASB rule NWT 308 and procedure NPR 703 did not provide sufficient description for the task of using protecting signals for an alternative route. (Safety issue)
The absence of authority-overrun protection (such as TPWS) at signal SST535 increased the potential consequences of a SPAD.
The train crew had not been trained to use forced lead function which would likely have allowed the train crew to regain control of the locomotives
