The Queensland Rail internal emergency debrief following the Cleveland station collision identified issues related to working with external agencies but did not address critical communication shortfalls within train control and between train control and the staff located at the Cleveland station accident site.
Poor wheel/rail adhesion was not recognised as a risk in any of Queensland Rail’s risk registers and therefore this risk to the safety of rail operations was not being actively managed.
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.
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.
The Queensland Rail driver’s manual did not explain the effects of low adhesion at the wheel/rail interface, how low adhesion is a precursor to prolonged wheel slide events and why these elements reduce the likelihood of achieving expected braking rates.
Though airborne search and rescue service providers were regularly tasked to provide assistance to pilots in distress, there was limited specific guidance on the conduct of such assistance.
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.
The Manual of Air Traffic Services differed from the Civil Aviation Safety Regulation Part 172 Manual of Standards concerning the requirements for issuing a night visual approach to an instrument flight rules aircraft, increasing the risk of ambiguity in the application of these requirements by controllers.
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.
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.
There is no available refuge or escape area within the traffic island at the northbound exit of the level crossing.
The Tiger Airways Australia Pty Ltd documentation and training package relating to the Avalon airspace structure and night visual approach guidance contained incorrect material and omissions that increased the risk of confusion and misunderstanding by flight crews.
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.
Local and national air traffic control procedures did not prescribe the means for controllers to indicate in the air traffic control system that a parachute drop clearance had been issued.
There was no documented procedure for assuring the separation of aircraft departing from Sydney with parachute operations at Richmond, increasing the likelihood that Sydney Terminal Control Unit controllers would have differing expectations as to their control and coordination requirements in respect of these operations.
In the past 25 years the ATSB and its predecessor have investigated 39 collisions between trading ships and smaller vessels on the Australian coast. These investigations have all concluded that there was a failure of the watchkeepers on board one or both vessels to keep a proper lookout and that there was an absence of early and appropriate action to avoid the collision.
Aerial work and private flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.
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.
