The rail safety authority has recommended changes be made after a crash involving an Albury-bound passenger train and large steel coil weighing 16 tonnes.
The steel coil fell from a Pacific National freight train at Winton, in north east Victoria, on March 30, 2018.
The freight train had crossed Seven Mile Creek bridge and the fallen coil caused track damage before obstructing both rail tracks.
A northbound V/Line train approached about 10 minutes later and hit the coil and damaged track at 110km/h.
The passenger train didn't derail despite the impact, but two staff received minor injuries.
They were standing at the time and were flung into benches and the sides of the buffet car.
It was unclear how many passengers were onboard, but none reported injuries.
The V/Line train had braked before the impact but was unable to stop in time and travelled nearly a kilometre while braking.
A report released by the Australian Transport Safety Bureau on Thursday found shortcomings in the way the coil was housed.
The lack of a rubber laid mat from one side of a cradle, and the likely failure of straps, allowed the inner layers of the coil to move.
This impacted the coil's stability and chance of movement.
Broken straps were found by investigators near the crash scene.
The freight company did not require the use of such mats.
The ATSB reported noted the importance of restraints.
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Pacific National had been unable to show that its load restraint system was safe and fit for purpose.
"Robust load restraint systems are required to protect against movement of loads during transport," the investigator said.
"This is particularly important for significantly heavy loads, such as jumbo steel coils, as should they fall from the train they pose a significant risk to the safety of other rail vehicles and passengers.
"The system should also include assessments and documentation that demonstrate appropriate load cases, design requirements, operational and loading requirements have been met, to ensure that the safety of the load restraint is maintained over time."
Pacific National has made changes since the incident.
Coils must now be held down by four straps and staff are encouraged to consider the condition of mats.
The safety investigator noted there were multiple reported instances of coils moving while being transported in recent years and one that had tipped over.
One wagon at Melbourne was found to have broken straps.
The ATSB recommended Pacific National implement further safety changes.
