Recommendations and Safety Advisory Notices

Safety issue
The helicopter operator's induction checklist did not include the notation of instructors' ratings and validity periods.

Action taken by the ATSB
Unless operators actively track the qualifications, endorsements, ratings and recency of their staff, there is the risk that pilots and instructors may operate aircraft with invalid qualifications and not be at the specified competency standard required for the task. Pilots, including those who have gained their Australian ratings as part of the Trans Tasman Mutual Recognition Act 1997, need to be aware of the different requirements regarding rating renewals in Australia. A valid rating is an important measure of competency.

Operators need to be able to assure themselves that pilots' qualifications are valid, and their competence confirmed when allocating tasks. On that basis, the ATSB issues the following Safety Advisory Notice.

Safety Advisory Notice AO-2009-032-SAN-019
The Australian Transport Safety Bureau suggests that operators and pilots should consider the safety implications of this safety issue and take action where considered appropriate.

The Australian Transport Safety Bureau draws the attention of all operators of CFM56-7 and CFM56-5 engines and their variants to the safety issues identified by this investigation. In particular operators should be aware of the potential for premature wear within the compressor variable stator vane bushings and shroud to develop to levels where it may precipitate the failure of the engine while in-service, and within a timeframe that is less than the minimum threshold for the initial inspection for the problem (24,000 hours TSN, per S/B 72-0515). Operators are encouraged to review their procedures to ensure an appropriate awareness of the issues among maintenance personnel.

Safety issue

There was a lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimised the risk of pilots operating outside the individual pilot's level of competence. [Minor safety issue]

Action taken by the ATSB

In response to this safety issue, the ATSB issues the following Safety Advisory Notice (SAN).

Safety advisory notice

The Australian Transport Safety Bureau (ATSB) draws the attention of all operators to the potential lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimise the risk of their pilots operating outside the individual pilot's level of competence. Operators are encouraged to consider the safety implications of this safety issue and take action where considered appropriate.

Significant safety issue

While most flag States have laws in place that implement the UNCLOS requirement for a ship's master to render assistance to the crew of another vessel
following a collision, these laws are not being effectively implemented on board all ships.

Safety advisory notice

The Australian Transport Safety Bureau advises that all flag States should consider the safety implications of this safety issue and take action where considered appropriate.

Minor safety issue

The evidence suggests that Class B AIS transmissions may not be reliably detected by watch keepers on board all ships. Therefore, operators of small vessels fitted with Class B AIS units should be aware that they cannot rely on the AIS unit alone to warn ships of their presence.

Safety advisory notice

The Australian Transport Safety Bureau advises that all owners, operators and skippers of small vessels should consider the safety implications of this safety issue and take action where considered appropriate.

Minor Safety Issue

The ARTC Code of Practice, with respect to Flooding, 'ETG-10-01', does not specify hydrological design parameters, including height of water ponding against the formation layer for a design precipitation event, and this could lead to under specified track drainage arrangements and an increased risk of track damage arising from flash flood events.

Safety Advisory Notice

The Australian Transport Safety Bureau advises that the Australian Rail Track Corporation should consider the implications of this safety issue and take action where considered appropriate.

Minor Safety Issue
The ARTC had not undertaken an audit of track drainage arrangements for the Trans-Australian Railway to verify that the track complied with the relevant standard and that the standard was appropriate.

Safety advisory notice

The Australian Transport Safety Bureau advises that the Australian Rail Track Corporation should consider the implications of this safety issue and take action where considered appropriate.

Minor Safety Issue

At the time of the derailment the ARTC did not have timely access to reliable weather information and may benefit by building closer relationships with the Bureau of Meteorology and local observers (councils, farmers, etc.) who could pass information to assist them with the identification of localised severe weather events that may potentially affect the safety of their track.

Safety advisory notice

The Australian Transport Safety Bureau advises that the Australian Rail Track Corporation should consider the implications of this safety issue and take action where considered appropriate.

Safety issue

The ship's safety management system working aloft procedure was not effectively implemented on board the ship and was not routinely followed when crew members climbed the emergency ladder to assist with the stowage of the cargo crane hook.

ATSB Safety advisory notice

The Australian Transport Safety Bureau advises that ASP Ship Management should consider the safety implications of this safety issue and take action where considered appropriate.

Safety Issue

The ship's health, safety, security and environment meetings and job hazard opportunity log were not effectively used to raise and discuss safety issues associated with cargo crane operations.

ATSB Safety advisory notice

The Australian Transport Safety Bureau advises that ASP Ship Management should consider the safety implications of this safety issue and take action where considered appropriate.

Safety issue

The design of the cradle for the cargo crane hook did not allow for unassisted stowage of the hook when the ship had a stern trim in excess of 2.1 m.

ATSB safety advisory notice

The Australian Transport Safety Bureau advises that Marlow Navigation should consider the safety implications of this safety issue and take action where considered appropriate.

Safety issue

The International Safety Management (ISM) Code requires ship owners to ensure that each ship's master is given all necessary support to fulfil their duties. However, Jevkon Oil and Gas did not provide the necessary support either before the commencement of the delivery voyage or after the ship's crew began having difficulties using the intermediate fuel oil in the main engine and started drifting in the Indian Ocean.

ATSB safety advisory notice

The ATSB advises that Jevkon Oil and Gas should consider the implications of this safety issue and take action where considered appropriate.

Safety issue

The ship's safety management system was inadequate. Had Jevkon Oil and Gas implemented an effective safety management system on board Breakthrough, the risk of an incident such as the one that occurred on the delivery voyage would have been reduced.

ATSB safety advisory notice

The ATSB advises that Jevkon Oil and Gas should consider the implications of this safety issue and take action where considered appropriate.

Safety issue

The ship's certification was issued by a management company to itself on behalf of the Republic of Sierra Leone, solely with the purpose of allowing the ship to sail on an international voyage and did not represent the ship's actual management or that any effective inspections of the ship or audits of the ship's safety management system had taken place.

ATSB safety recommendation

The ATSB recommends that the Sierra Leone International Ship Registry should address this safety issue.

Safety issue

The operation of the ship's systems and the decisions made by the ship's senior officers suggests that they did not have sufficient relevant knowledge and experience to safely undertake Breakthrough's delivery voyage and they did not effectively use the time spent in China, standing by the ship, to acquire the necessary knowledge.

ATSB safety advisory notice

The Australian Transport Safety Bureau advises ship owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.

This incident highlights the potential for unintended consequences when changes to standard operating procedures are introduced without first conducting an appropriate risk analysis. Therefore, the ATSB advises that all aircraft operators should consider the safety implications of this safety issue and take action where considered appropriate.

Safety issue
The process for identifying potential rail defects is limited by the ultrasonic test vehicle operator's ability to detect and assess the echo patterns correctly.

Action taken by the ARTC
Rail Technology International (RTI) is actively conducting further development of their ultrasonic testing process. For example, RTI are developing software based on 'Artificial Neural Networks' for recognising ultrasonic reflection patterns that represent potential rail defects such as bolt-hole cracks. RTI have conducted post test re-analysis of ultrasonic test data using the neural network software to identify any defects that may have been missed during the test run. RTI's plan is to run the neural network software in the background and conduct this analysis while ultrasonic testing is being undertaken. RTI have indicated that implementation is planned for early 2010.

ATSB assessment of action
The ATSB acknowledges that the ARTC and RTI are developing processes to reduce the risks associated with operator dependence. While some of those
initiatives have been introduced, especially in relation to bolt-hole cracks, other rail defects are also exposed to the issue of operator dependence. The opportunity exists for continued development and implementation of strategies aimed at reducing operator dependence.

ATSB safety advisory notice RO-2008-005-SAN-035
The Australian Transport Safety Bureau advises that the ARTC should consider the implications of this safety issue and take action where considered appropriate.

Safety Issue
The ARTC Code of Practice does not recognise the relationship between heataffected metal and stress concentration when specifying how far a bolt-hole should be from the rail ends before welding.

ATSB safety advisory notice RO-2008-005-SAN-036
The Australian Transport Safety Bureau advises that the ARTC should consider the implications of this safety issue and take action where considered appropriate.

Safety issue

The ARTC Code of Practice does not clearly address the possibility that a series of track irregularities, even minor ones which do not exceed intervention limits, could cause an undesirable harmonic response in some rail vehicles.

ATSB safety recommendation

The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes safety action to address this safety issue.

Australian Rail Track Corporation recognises the issue identified by the Australian Transport Safety Bureau investigation and is undertaking research to identify a sustainable and practical approach to address the issue.

Australian Rail Track Corporation accepts that the track maintenance standard as currently applied treats each identified track geometry deficiency as a separate entity and may not fully recognise that there may be rare but possible combinations of track geometry deficiencies and rail vehicle ride characteristics that can unite to initiate a derailment.

The identified deficiency relates more the spacing of minor track geometry deficiencies in combination with rail vehicle characteristics including bogie spacing and type, wheel profile and load placement than the size of the individual geometry deficiencies.

Australian Rail Track Corporation has a robust electronic track geometry measuring system in place with significant data captured and processed to generate a Track Quality Index (TQI) for any given track section.

Research undertaken to date indicates the problem is not unique to the NCoP applied by Australian Rail Track Corporation, a review indicates that other codes applied within Australia and overseas have yet to define a systemic and sustainable long term solution to the problem.

Australian Rail Track Corporation considers that the issue is worthy of further consideration and has established a project group to review current standards and practices including the concerns raised by Australian Transport Safety Bureau.

The ATSB is satisfied that the intended action by the ARTC would adequately address the safety issue.

Safety Issue

The trailing bogie of wagon RCPF-31882C was found to have loose and broken wedge wear plates. It could not be verified whether the wedge wear plates had broken free before or during the derailment sequence. However, if the condition had existed prior to the derailment, it is likely that body roll induced while traversing a series of track irregularities could result in undamped harmonic oscillations.

ATSB safety recommendation

The Australian Transport Safety Bureau recommends that Pacific National takes safety action to address this safety issue.

PNL has train examination procedures in place for these items. It is also included in the new version of the Pacific National Wagon Pocket Field Manual

The ATSB is satisfied that the intended action by PNL would adequately address the safety issue.