A passenger train was travelling at more than 100kmh 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 and eight passengers were seriously hurt and another 58 people sustained minor injuries.
The Australian Transport Safety Bureau's final report into the crash was released on Wednesday and made 37 findings 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 15kmh, the passenger train was travelling at speeds of between 114kmh and 127kmh.
"There was no protocol in place to confirm the driver's understanding of the revised instruction," bureau 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.
The train driver had been through the straight section of track eight times in the 12 days before the derailment but he had never been diverted through the Wallan loop.
It was likely on the day of the derailment he was not aware there was a change of route and he expected to travel through the straight section where the speed limit was 130kmh.
He would have been given a hard-copy notice advising him of the new route, but there was no process in place that required him to confirm with network control he understood the changes.
Two V/Line services had successfully made their way through the Wallan loop in the hours before the XPT passenger train derailed.
V/Line had briefed their crews about the changes but NSW Trains did not, Mr Mitchell said.
"We know that the V/Line system did have greater checks and balances in place," he said.
