Australian Transport Safety Bureau Investigation Findings
Firstly, the prima facie cause of the derailment was that the train was travelling at an excessive speed – 112 km/h (70 mph) at the beginning of a curve with a posted speed limit of 60 km/h (37 mph). The lead power car rolled, dragging most of the remaining cars off the track. The driver did not reduce the speed of the train before it entered the curve where it derailed. The investigation believed that there was no evidence that the driver deliberately ignored speed limits or drove in excess of limits, nor that he intended the train to derail. Up to the time of the derailment, the train was in steady power, and the train's brakes were not activated until just before it derailed. The report found that the driver may have been disorientated or distracted up to the curve, and did not recognise the geographic proximity and where the train was at the time.
At 417.733 km (259.567 mi) from Brisbane, 1.76 km (1.09 mi) and 61 seconds before the derailment, the posted speed limit for the Tilt Train was 150 km/h (93 mph), an increase from 110 km/h (68 mph). The report found that it may have been possible that the driver mistook the midsection alarm to be the station protection magnet alarm located before Baffle. After the curve where the train derailed is a similar layout of track, where, after an increase of the speed limit to 150 km/h (93 mph), is a left curve with a speed limit of 110 km/h (68 mph) before Baffle.
The report also found that the driver may have left the driving position for a moment to get food from his bag or the train's mini fridge, under the belief that it was safe to do so. After reorientating himself returning to his seat, it would have been too late to apply the emergency brakes with the train travelling too fast.
The second driver absence from the drivers' cabin removed one of the primary defenses of having two drivers in the cab to avoid errors made by just one. The co-driver sits to the right of the driver, and their main task is to observe that the driver is controlling the train safely, to watch the direction the train is travelling and call signals verbally to which the driver acknowledges. The co-driver can intervene in the control of the train should the driver not react appropriately. Before the derailment, there was no requirement for the co-driver to call-out critical speed limit changes, nor prohibit the co-driver from leaving the drivers' cabin to, say, prepare beverages in the adjacent area.
The weather condition in the area was fine, wind was low, and the temperature was 24.5 °C (76.1 °F). The moon had set at 7:23 pm, over four hours earlier, and was 26° below the horizon, meaning that while visibility was good, the area the train was operating was in complete darkness. With the exception of the illumination given by the train's headlights, this darkness exposed a weakness in another of the train's protection methods – drivers having knowledge and competence of the route they operate in – as landmarks cannot be seen and drivers' field of view is reduced and their spatial awareness compromised.
Read more about this topic: Cairns Tilt Train Derailment, Investigation
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