The Skitube system for managing access to track did not detect the conflict of the rail maintenance worker under the train at the same time the train was being shunted.
The Robinson R44 pilot’s operating handbook low rotor RPM recovery procedure did not include reference to the minimum power airspeed for the helicopter as a consideration, which may assist a pilot to recover from a low rotor RPM condition. [Safety Issue]
Professional Helicopter Services did not have a calibration schedule for their passenger scales, which were under-reading. This increased the risk of their helicopters not achieving their expected take-off performance.
Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combined roles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation alert or runway incursion alert at their workstation.
The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient to effectively reduce the risk of a runway incursion.
Although Qantas provided detailed guidance to flight crews about the content of departure and approach briefings, it did not specifically require aerodrome hot spots to be briefed.
VicTrack’s contractor, UGL Engineering Limited, did not provide signalling testers with specific instructions detailing the scope of work to be conducted at each stage of a project, but rather, only provided packaged isolation plans for the entire project. The absence of these instructions increased the risk of the works being incorrectly implemented.
The procedures in the aircraft maintenance manual relating to chip detector debris analysis were written in a way that could cause confusion and error. This probably influenced the actions of the maintenance personnel to release the aircraft to service with a deteriorating bearing.
No procedure or system was in place to ensure critical spares were identified and their inventory controlled to ensure availability when required. As a consequence, the fan belts for the emergency generator had been on order for several months.
Aurizon did not provide drivers with ready access to Queensland Rail’s procedures for driver only operations and overhead line equipment emergencies when they were operating on the Queensland Rail network. In addition, Aurizon did not have procedures for driver only operations that applied to its own network.
Aurizon did not have an effective system in place for ensuring personnel required to check the securing of unusual loads (such as empty flat racks) prior to departure had sufficient knowledge of their responsibilities, and had ready access to relevant procedures, guidance and checklists.
The power turbine shaft in Pratt & Whitney Canada PW100 series engines operating in certain marine environments is susceptible to corrosion pitting, which can grow undetected between scheduled inspections. This increases the risk of shaft fracture resulting in engine failure.
The visual flight rules permitted balloons to arrive and depart in foggy conditions without assurance that sufficient visibility existed to see and avoid obstacles.
Cloncurry Air Maintenance had adopted a number of practices, which included using abbreviated inspection checklists, not recording all flight control disturbances and not progressively certifying for every inspection item as the work was completed, which increased the risk of memory-related errors and the omission of tasks.
Aurizon’s procedures and guidance for two-driver operation during situations such as a condition affecting the network (CAN) did not facilitate the effective sharing of duties and teamwork to minimise the potential effects of degraded conditions on driver workload and fatigue.
Queensland Rail did not have any restrictions on the distance or time that controlled speed could be used as a risk control for safe train operation in situations such as a condition affecting the network (CAN). The effectiveness of controlled speed has the significant potential to deteriorate over extended time periods due to its effect on driver workload, vigilance, fatigue and risk perception.
Queensland Rail did not have procedures that required network control personnel to actively search for information about track conditions ahead of a train during situations such as a condition affecting the network (CAN), when conditions had the realistic potential to have deteriorated since the last patrol or train had run over the relevant sections.
Queensland Rail did not have an effective means of ensuring that, during situations such as a condition affecting the network (CAN), network control personnel were aware of the relevant weather monitoring systems that were unserviceable.
Sydney Trains' control of the access and egress to the project worksite did not ensure that all workers entering the worksite were identified and received an induction.
The scheduled inspections recommended by Rolls-Royce to detect cracking in Trent 700 fan blades, were insufficient to detect early onset fatigue cracks in the membrane to panel bond before those cracks could progress to failure.
