Adams, Jamie Christopher; Watkins, Gary Robert - Non-inquest findings

Contributing factors

• Defective lighting on track machine impairing visibility
• Failure to conduct proper Daily Service Checks
• Failure to conduct Worksite Safety Briefing
• Lack of communication between work crews
• Inadequate supervision by Resurfacing Supervisor
• Reversing operation at excessive speed (20 km/h vs required 10 km/h maximum)
• Train driver operating from trailing cab without line-of-sight visibility
• Failure to use forward-facing cab for reversing operation
• Groundperson boarding machine instead of maintaining ground position
• Noise from passing coal train masking warning signals
• Ineffective rear-vision camera system
• Failure to scan reversing camera continuously
• Lack of vigilance by deceased workers
• Failure of supervisor to maintain communication via radio
• Fatigue in crew members from inadequate rest periods
• Lack of appointed Track Protection Officer
• No positive site handover between work crews
• Mechanical defects including failed beacon lights and damaged headlight

Coroner's recommendations

1. Implementation of consistent and effective Worksite Safety Briefings
2. Ensuring preconditions to reversal of vehicles in accordance with Queensland Rail safe working requirements are met
3. Review of responsibilities and training syllabi for Resurfacing personnel
4. Implementation of pre-departure safety checks on Infrastructure Services Group trains
5. Provision of safe separation and segregation between track workers and trains
6. Safety Management System compliance monitoring at local level
7. Implementation of effective fatigue management within Queensland Rail, particularly Infrastructure Services Group rostering
8. Management of relationship between Infrastructure Services Group and Network Control
9. Awareness of priority of safety over commercial pressures by remote staff
10. Distribution of safety communications and documents within Queensland Rail
11. Representation for relevant stakeholders in operational change management processes
12. Risk and change management training for Infrastructure Services Group operational personnel
13. Assessment of safety risks presented by permanent coupling of track machines
14. Enhancement and transparency of reporting systems
15. Management of Infrastructure Services Group district staff relationship issues
16. Infrastructure Services Group and Network Access radio protocol compliance monitoring
17. Introduction and maintenance of risk-based approach to audit processes by regulator
18. Monitoring of occurrence reporting effectiveness and safety climate
19. Enhancement of regulatory workforce capability in human performance and limitations
20. Consideration of confidential occurrence reporting program
21. Provision of safety awareness activities to promote safety culture in Queensland rail industry