Safety Issue
TransAdelaide's SPAD investigation process was unlikely to have
provided a clear understanding of factors that may have contributed
to past SPADs or a sound basis for identification of safety actions
to prevent similar occurrences. A recommended action in
TransAdelaide's SPAD risk management plan was the establishment of
a SPAD investigation group to investigate individual SPADs, compile
data, conduct analysis, determine trends, make recommendations,
report and oversee implementation. It was not evident that this
recommendation had been fully implemented at the time of the
incident.
Safety Recommendation
The Australian Transport Safety Bureau recommends that
TransAdelaide undertake further work to address this safety
issue.