Although Airservices Australia used applied operational risk assessments to high-level threats, it did not formally assess and manage the risk of specific threat scenarios. As a likely result, Airservices did not formally identify and risk manage the threat of separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport, even though it had been a known issue among controllers generally.
The methods used in the Australian Standard AS 1742.7:2016 to calculate safe stopping distances, and determine the need and location of advanced warning signs for road approaches to level crossings, did not account for the likelihood of detecting the level crossing ahead based on the normal visual focal points of road drivers negotiating a curved road. While the standards included guidance for the use of active warning signs for curved road approaches to flashing light controlled crossings, this was not mandatory.
The Australian Transport Safety Bureau recommends that NSW Trains undertake further work to improve the methods used to provide safety information to ensure that passengers are given a reasonable opportunity to gain knowledge of what they may be required to do in the event of an emergency.
The Australian Transport Safety Bureau recommends that Airbus takes safety action to address the effectiveness of the mitigations to the design limitation associated with the A330 cabin pressure control systems.
