Southern Shorthaul Railroad's (SSR's) training and assessment did not include coupler functionality and the process to ensure correct coupling had occurred. Further, an underpinning procedure for the stretch test (effectively coupled) process did not exist.
There was probably no independent check of the isolation arrangements installed on the night of 29 November. An earlier internal audit of the project also reported instances of testers in charge checking their own work.
Metro Trains Melbourne standards and procedures did not specifically address requirements associated with fuse removal and securement in safety critical scenarios.
Changed level crossing isolation arrangements were not effectively reflected in program documentation, nor effectively disseminated to all those potentially affected. An earlier internal audit of the project also identified instances of scope changes not being documented.
The check pilot system was ineffective in providing the Australian Maritime Safety Authority (AMSA) assurance of the competency of coastal pilots, mainly due to the inconsistent and unreliable application of assessment standards between different check pilots. Further, AMSA had not implemented a system to identify the inconsistent application of standards or the trends in assessment outcomes readily apparent in the data that it had held for many years.
Response by the Australian Maritime Safety Authority
Due to topography and buildings at Mildura Airport, aircraft are not directly visible to each other on the threshold of runway 09, 27 and 36. The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.
Swissport did not ensure that the implemented training and audits for Link Airways Saab 340B dispatches incorporated all of the elements required in its Ground operations manual for pre‑departure walk-arounds.
Guidance provided by Link Airways for training of Swissport dispatch coordinators did not explain the appearance, function and importance of the propeller straps.
The propeller strap did not have a high-visibility streamer attached, and Link Airways did not effectively manage the condition of propeller straps for its Saab 340B fleet. This affected the visibility of the straps during ground operations.
On one-third of the Link Airways Saab 340B flights for which video surveillance was examined, including the occurrence flight, the flight crews did not fit the strap extension between the propeller strap and the airstairs. As the cabin door could not be closed with the strap extension in place, its correct fitment would almost certainly prevent a flight from proceeding with a propeller strap fitted.
An earlier version of the helicopter operations checklist was used by the crew of the Tai Keystone. That checklist did not include a requirement, present in the version current at the time of the incident, to remove handrails or stanchions from the helicopter landing site.
Although National Jet Systems contained procedures for recognition and management of pilot incapacitation, the associated training did not include the identification and response to subtle physical or cognitive incapacitation.
National Jet Systems’ cabin air quality events procedure focused on the recording/reporting of odours, post-flight care of crew and maintenance actions. However, it did not consider the possible application of the smoke/fumes procedure, or incapacitation procedure. As a result, there was an increased risk of flight crew being adversely affected by such an event during a critical stage of flight.
Although suitable for use in most situations, the streamers attached to the pitot probe covers supplied and used for A350 operations by Heston MRO at Brisbane Airport provided limited conspicuity due to their overall length, position above eye height, and limited movement in wind. This reduced the likelihood of incidental detection of the covers, which is important during turnarounds.
The majority of Singapore Airlines flight crews (observed around the time of the incident) did not fully complete the required pre-flight walk-around inspections.
Heston MRO did not track the work-related hours of personnel with dual management and operational roles (including the licenced aircraft maintenance engineer) for fatigue calculation purposes. Therefore, there was an increased risk of a fatigue related incident involving those personnel.
Heston MRO had not yet implemented a previously proposed and accepted method to account for tooling and equipment (such as pitot probe covers) prior to aircraft pushback.
Arc Infrastructure’s procedures included no requirement for a network control officer (NCO) to make an emergency call and advise potentially ‘at risk’ trains that another nearby train had overrun its limit of authority.
The Arc Infrastructure processes for the management of rail traffic overrunning its limits of authority were reliant on the immediate actions of the rail traffic crew and did not explicitly require immediate actions from the network control officer (NCO). This situation increased the risk of driver completely missed signal passed at danger (SPAD) events, particularly in cases where the rail traffic crew’s awareness or capacity was potentially compromised.
The Arc Infrastructure practice of pathing a following train up to the same section of track occupied by a stopped train, coupled with no requirement for the network control officer (NCO) to communicate and confirm rail traffic crews were aware when approaching another stopped train, increased risk.
