What went wrong?

Mr Strachan said the problems did not stem from one issue,but compounding issues that"accumulated over time".

While demand for train crew grew significantly,supply of qualified drivers declined,limitations meant the growing gap between supply and demand was not widely appreciated,and QR's unclear governance arrangements made it difficult for the chief executive officer to maintain oversight.

A train driver shortage became apparent to the public following the opening of the Redcliffe Peninsula Line in October 2016,with hundreds of services cancelled in the following months.

But QR realised it might not have enough crew for the new line in mid-2015,beginning internal recruitment of 100 drivers and 100 guards.

The driver shortage was caused by several issues,including a QR preference to operate with a 5-10 per cent undersupply of train crew and a consequent over-reliance on overtime - which boosted pay packets.

In the months leading up to the new timetable in October,QR staff worked unsustainable levels of overtime.

There were restrictions on external recruitment,and a 12-month halt of driver training from February 2014,and then training took about 18 months on average - twice as long as it should - with small class sizes.

"Increasing demand and decreasing supply opened up a gap of around 100 drivers at the end of last year,a shortfall,"Mr Strachan said.

"That gap has been traditionally closed by the use of overtime but in the end of October that lever of overtime became exhausted and could no longer close that gap."

Who was to blame?

Mr Strachan said he did not think people deliberately hid the truth,but there was an unwillingness to share"bad news".

"There were people down deep in the organisation that were having some concerns about some shortfall issues as far back as 2015 but there wasn't a clear communication upwards into middle management and senior management to the CEO,to the board or to the responsible ministers,"he said.

"I don't think there was any deliberate attempt to hide information – we touched on some cultural issues within the organisation,perhaps not always being willing to share some bad news or share issues.

"I'd like to see that culture change going forward."

Mr Strachan pointed to accountability issues and communication failures.

He said the senior manager for train service delivery was focused on 58 hours ahead,but did not take action in the medium to longer term.

Mr Strachan said the general manager Citytrain was inexperienced and saw issues but did not have the confidence to raise them at the right time.

After pointing out other issues at senior levels,Mr Strachan said the chief operating officer did not raise issues or challenge assumptions.

Mr Strachan said chief executive officer Helen Gluer sought some assurances but was relying heavily on her chief operating officer,and did not challenge what she received.

He said the board was being briefed by the executive,which was not aware of the emerging issue,so the board was not being properly informed,and in turn did not advise ministers until October 2016.

Mr Strachan recommended QR confirm the senior manager for train service delivery should be accountable for managing supply,demand and responses to projected train crew shortfalls for at least a rolling eight-week forecast period.

Despite both sides of Parliament levelling the blame at each other in recent months,Mr Strachan said neither the present Labor government or previous LNP government were at fault.

Premier Annastacia Palaszczuk said Mr Strachan had uncovered issues that lay dormant for years.

Who has lost their job?

Stirling Hinchliffe is the latest to lose his job over the saga,stepping down as transport and Commonwealth Games minister.

He followschief executive officer Helen Gluer,chairman Michael Klug andchief operating officer Kevin Wright,who all resigned,with thehead of train service delivery being stood down.

And there are more job losses to come.

Mr Strachan has recommended eight layers of management become five layers and the role of chief operating officer be scrapped.

The Director-General of the Department of Premier and Cabinet has also referred the report to the Public Service Commissioner.

The Commissioner has been asked to consider whether the conduct of any Queensland government employees referred to in the report should be the subject of a disciplinary process under the Public Service Act 2008.

What were the other recommendations?

QR should develop a five-year rolling monthly forecast of demand and supply for train crew,a shake-up of managers'roles and discuss rules around working time,meal breaks and rostering processes with unions.

QR should maintain a surplus of train crew to make sure operations can be conducted without the systemic reliance on overtime and tutors and inspectors having to take on operational roles.

Recruitment should be opened externally and to people with no experience,with an ongoing recruitment.

Training should also be sped up to nine months or less,with the curriculum overhauled.

Staff should be encouraged to proactively escalate potential issues to senior management,and communication to government overhauled.

The ratio of supervisors to train crew should also be increased significantly to improve the relationship and information flow between management and train crew.

Reporting to TransLink and the public should also be improved,so people can plan alternative travel arrangements when issues arise,with information to be available in real time at stations,online and through the call centre.

What happens next?

Premier Annastacia Palaszczuk has committed to all 36 recommendations.

This includes establishing a new Citytrain Response Unit,for an initial period of 12 months,to act as a watchdog for QR,ensuring it stays on track.

But do not expect a quick fix as Mr Strachan said it would take two years for some of the 36 recommendations to take effect.

Ms Palaszczuk said it was important to open up QR driver positions to external recruitment as soon as possible.

"It should take around nine months to train a driver,especially if we look at the learning of the driving on sectors of the railway network,"she said.

QR expects it will have sufficient train crew to deliver the full timetabled services by late 2018,assuming 10 per cent overtime,or mid to late 2019,assuming no overtime.

The report states:"It is the Commission's view that Queensland Rail has made limited progress in this regard since October 2016."

Until there is enough crew to deliver the full timetable,QR will continue to operate with reduced services and high levels of overtime,the report reads.

Ms Palaszczuk has also pledged her government would work with the union.

Mr Strachan will meet shortlisted candidates for the position for chief executive officer on Friday.

QR has also been directed to provide a high-level response plan within 30 days.

Opposition Leader Tim Nicholls has asked for a comprehensive briefing with Mr Strachan on Tuesday.

"Following that,I will outline the LNP's full response to the issues raised in regards to Queensland Rail,"he said.