crash were examined and were also found not to have had pre-existing damage able to cause such an accident. Official findings into the accident also blamed an "underdeveloped safety culture". There has been criticism of the way CityRail managed safety issues, resulting in what the NSW Ministry of Transport termed "a reactive approach to risk management". At the inquiry, Paul Webb, Queen's Counsel, representing the guard on the train, said the guard was in a microsleep at the time of the question, for as much as 30 seconds, which would have removed the opportunity for the guard to halt the train. Webb had also proposed there had been attitudes that the driver was completely in charge of the train, and speeding was not an acceptable reason for the guard to slow or halt the train, which would have been a contributing factor in the accident. Prior to this derailment, neither training nor procedures mandated the guard to exercise control over the speed of the train by using the emergency brake pipe cock ("the tail"). Apart from the driver being considered to be the sole operator of the train, the emergency brake pipe cock does not provide the same degree of control over the automatic brake as a proper brake valve. The consensus among train crews was that a sudden emergency application from the rear could cause a breakaway (which is in fact not possible, as the cock does not apply the brakes solely to the rear car but rather uniformly along the full length of the train), and there was some evidence from previous accidents to validate such an opinion, however these were not involving the modern multiple-unit train design of which the Tangara is an example. Since this derailment, CityRail training and operational procedures now emphasise the guard's responsibility to monitor the train's speed, and if necessary, open the emergency brake pipe tap to stop the train. Changes implemented All Sydney and Intercity NSW Trainlink trains now have an additional safety feature, which has been fitted since the accident. In addition to the deadman handle and foot pedal, the trains are fitted with "task linked vigilance" - which resets a timer every time the driver activates certain controls. If there is no change in control, a flashing lamp and then buzzer sound and the driver is required to acknowledge a vigilance button. If the train's driver does not use