A passenger train was travelling at more than 100km/h over the speed limit when it derailed north of Melbourne, killing its driver and a rail worker.
The NSW Trainlink XPT passenger train was on its way to Melbourne from Sydney on February 20, 2020, when it came off the tracks at Wallan.
Experienced driver John Kennedy, 54, and 49-year-old rail worker Sam Meintanis were killed, while eight passengers were seriously hurt and another 58 people sustained minor injuries.
The Australian Transport Safety Bureau's final report, released on Wednesday, August 9, made 37 findings following the incident, including in relation to 15 safety issues.
On the day of the derailment, the train was diverted through the Wallan loop track because the signalling system was down on the straight section of track that was part of the normal route.
Instead of entering the loop section at the required 15km/h, the passenger train was travelling at speeds of between 114km/h and 127km/h.
"There was no protocol in place to confirm the driver's understanding of the revised instruction," ATSB chief commissioner Angus Mitchell said.
There was also no evidence to suggest the driver was incapacitated or there was a track defect that led to the derailment, the report found.
– AAP Newswire