Passengers are evacuated from the derailed train at Edgecliff in January last year. Credit:Annie Dang While no one was injured in the incident, investigators said oversight of the train from the first sign of trouble at Central to the response to the derailment at Edgecliff revealed inadequacies in areas ranging from communications, training and command to control and culture. "There was, from the initial report to the on-site management post-derailment, an inability to effectively manage the incident," investigators said in the report. Investigators also found that the train's crew did not respond to passengers activating emergency alarms. The report details a litany of missed chances for staff and Sydney Trains' management centre to avert the derailment. The first sign of trouble was detected at Central Station when staff and crew smelt something burning and saw smoke rise from the train as it was about to head towards Bondi Junction.

The metal bar that tore through the floor of the third carriage and hit its ceiling. Credit:Annie Dang By the time the train got to Martin Place, the burning smell was such that a duty manager called Sydney Trains' emergency response unit for fire engines to be sent in case there was a fire. Yet the train continued on to Kings Cross, where its guard and a staff member inspected the suspect carriage but, apart from a "bit of a smell", could not see anything wrong. While multiple conversations occurred between station staff, train crew and within Sydney Trains' rail management centre, investigators said the train's condition was not reported to the right control officer as was expected under guidelines and "no one person was aware of all the facts". At Bondi Junction, the train driver noticed "quite a plume of smoke", while an attendant became "increasingly concerned about the amount of smoke" and the burning smell.

The attendant was so concerned he made an emergency "fire, fire, fire" broadcast on his hand-held radio to alert other station staff. The station's duty manager called the rail management centre to request units be sent from both NSW Fire and Rescue, and Sydney Trains' emergency response unit. However, train crewing staff assumed sticking brakes were the cause of the smoke and decided to allow the train to return to Central where a train technician could inspect it. The train eventually departed Bondi Junction with a new trainee driver, a supervisor and a train crew shift manager who rode in the third carriage to listen for any abnormal sounds. Shortly before the derailment, an attendant on a platform at Edgecliff spoke to the train's guard about his concerns after seeing smoke and noticing a burning smell. He told the station's duty manager, who agreed the train should go no further. But while the train's guard, who was speaking on his personal mobile, acknowledged the attendant's concerns, he took no action and the train continued on its way to Kings Cross.

As it departed, a wheel of the leading axle on the third carriage derailed just past the end of the platform, and a bar that became dislodged from the track was propelled through the floor of the third carriage, narrowly missing passengers and hitting the ceiling. While the train came to a stop after a little over 200 metres, the driver looked out along the side of the train but could see nothing untoward. He intended to push on to Kings Cross but a short time later passengers knocked on the driver's compartment to alert him and he discovered that the train had derailed. Apart from highlighting the deficiencies at Sydney Trains, the ATSB said an "unauthorised, non-standard repair" had been carried out on the axle that eventually broke on the train's third carriage in late 1998 or early 1999. That caused stress and a crack to develop over time to the extent that the axle eventually failed. Sydney Trains later discovered that a further six train axles had been repaired in the same way, all of which were removed from service. Shortly after the incident, Sydney Trains chief executive Howard Collins said the train "left Bondi under normal conditions, it arrived at Edgecliff station and departed normally".

On Thursday, Mr Collins said in a statement that the derailment had alerted Sydney Trains to a "number of issues, which we have acted on to improve our safety performance". He said the agency was "proactive after the incident", carrying out 18 safety actions following an internal investigation.