Authorities say a train crash at Cleveland on Brisbane's bayside was caused by a slippery mix of leaves, oil and rain on the tracks.
The passenger train ploughed into the Cleveland Station building in late January, leaving 19 people with minor injuries.
The train overshot the end of the tracks and travelled 10 metres inside the station, demolishing a toilet block.
An has found Queensland Rail (QR) had not sufficiently mitigated the risk of environmental conditions.
The investigation found the track was closed due to severe storm activity for three days prior to the accident.
ATSB chief commissioner Martin Dolan says contaminants on the line caused the train to slide into the station.
"It was mostly leaf and wood - there'd been trees down on the line previously," he said.
"It had been closed and they'd been cleared, but some of that had been crushed into the rail.
"There were natural oils and also the oils that just come from trains passing over it.
"It ends up when there's a bit of water added into it in a pretty slippery sort of mixture."
Mr Dolan says the driver did everything he could to try to stop the train.
"He braked as normal, then when that didn't slow the train as expected, he applied full braking and emergency braking," he said.
"He did that in accordance with how it should have been done and no problems we could see.
"There was nothing the driver could have done - the train was just going to keep on going."
The report also pointed out that unlike older trains in the QR fleet with 'wheel-tread brakes', the newer models appear particularly susceptible to 'wheel slide' in slippery conditions.
Transport Minister Scott Emerson says while the circumstances surrounding the crash are rare, the report should should act as a wake-up call.
"Queensland Rail is already putting in procedures based on this report and what happens overseas to deal with these issues moving forward," he said.
Mr Emerson says the ATSB has told him the new brakes are still safe.
"These brakes on these trains do work better than the old trains, except in these circumstances," he said.
"QR will now look to identify black spots where potentially this could happen," he said.
"It is also about making sure if there is some evidence this may be occurring, that there's drivers who are appropriately trained to manage the trains, to be able to deal with that, in terms of speeds and stopping distances."