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THE final report into the crash of a Queensland Rail tilt train blames excessive speed and says the driver did not cut the throttle as he entered a bend, possibly because he was distracted.
And it confirms that the co-driver was not in his seat when the train crashed off the rails at Beradjondo, north of Bundaberg, injuring more than 120 of the 157 passengers and crew.
The report, to be presented shortly to Queensland Cabinet by Transport Minister Paul Lucas, makes 11 recommendations to improve running safety, some of which have already been implemented.
One is the introduction of automatic train protection systems on electric tilt trains running to Rockhampton. The diesel-hauled Cairns trains will be equipped by early next year.
The ATP supplies drivers with information about approaching corners, track grades, signals, speeds and braking distances. If the driver does not respond to an alert, the train stops.
Before the tilt train crash, the systems were fitted to driver-only freight locomotives and the Sunlander, the other long distance train between Brisbane and Cairns. But the Sunlander can do nothing like the 160km/h of the tilt train, which can top 200km/h.
The diesel-drawn City of Townsville was heading to Cairns from Brisbane when the derailment occurred a few minutes before midnight on November 15 last year.
It was travelling at 112km/h as it approached a bend where it should have been doing 60km/h.
According to the report prepared by Queensland Rail and the Australian Transport Safety Bureau, the driver possibly became distracted and did not realise how close he was to the bend.
The absence of the co-driver meant there was no one to act as a backup in the event of driver error.
Yet the safe passage of the train depended on joint driver operation, external prompts and track knowledge.
The report says QR should review its monitoring and training of drivers who have been involved in "non conforming" situations and reassess the circumstances when a co-driver can vacate his seat.
It should look at the benefits of a passenger restraint system on tilt trains and review the effectiveness of briefings on safety to boarding travellers. And the crash survivability of emergency exit systems should be tested.
The effectiveness of emergency communication strategies for the Brisbane-Cairns line should be reviewed and QR should overhaul the way passengers are evacuated where overhead electrical wires may be live.
The report says that next year the tilt trains – not currently running at top speeds – will be allowed to travel faster as a result of the recommendations.
But before this can occur QR will have to get Queensland Transport approval through a safety validation clearance.
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