Concerns were raised about the safety of remote control technology in the lead-up to a driverless freight train speeding uncontrolled for more than 20 minutes in Tasmania, ultimately resulting in two people being struck with flying debris when it was forcibly derailed.
The runaway TasRail train was loaded with cement and would not respond to attempts to stop it from leaving the yard in September 2018.
Over the course of 23 minutes, the train sped from Railton to Devonport through 13 public level crossings and past homes and businesses, reaching a maximum speed of 87.5 kilometres per hour.
It only came to a stop when it was deliberately routed into a dead-end siding opposite the Spirit of Tasmania ferry terminal, where two people were struck by debris from a fence and suffered minor injuries.
The Australian Transport Safety Bureau (ATSB) identified multiple safety issues, all of which have now been resolved, mostly relating to TasRail's use of remote control technology.
In the bureau's final report into the incident, Chief Commissioner Angus Mitchell said the technology had "several safety-related design and integration problems that were readily identifiable".
There were 281 system faults that were identified between February and September in 2018, including one where a driver reported it was unsafe for use.
It was identified there were design flaws which meant there were unintended brake releases.
"Since the remote control system was designed, there have been substantial improvements in the quality and availability of systems safety guidance for complex rail systems in Australia," Mr Mitchell said.
"However, it is important this accident serves as a reminder for a heightened focus on systems safety from all transport operators and manufacturers, into the future."
Following the incident, TasRail suspended the use of the technology but is working to reintroduce it.
"TasRail has established a project team to lead the reintroduction of remote control technology for terminal operations at Railton and Devonport," a TasRail spokesperson said in a statement.
"The reinstatement process will include all lessons learnt relevant to the safe reintroduction and use of remote technology.
"Safety is one of TasRail's core values, and it is committed to zero-harm for staff, customers, contractors, and the communities in which it operates."
Mr Mitchell praised the actions of TasRail staff on the day of the incident as well as the response from Tasmania Police officers who kept key level crossings clear as the train passed.
All of the safety issues identified have now been addressed or are being addressed, including TasRail installing catch points to prevent uncontrolled train movements and improving its emergency response procedures.
