The Trent 700 blade manufacturing process produced a variation in internal membrane-to-panel acute corner geometry that, in combination with the inherent high level of blade panel stress, could lead to increased localised stresses in those corner areas and the initiation and propagation of fatigue cracking.
The Civil Aviation Safety Authority provided no guidance for operators concerning the risks associated with vehicle‑assisted deflation.
Picture This Ballooning's safety risk management processes and practices were not sufficient to facilitate the identification of key operational risks associated with vehicle-assisted deflation.
Picture This Ballooning did not have any procedures for conducting vehicle-assisted deflation.
Queensland Rail did not have a procedure in place to cross-check a master circuit diagram with the existing configuration of the in-field equipment before using the diagram for safety critical work. This removed an opportunity to detect any error in master circuit diagrams.
There were track defects identified in the vicinity of the derailment site prior to the derailment. The maintenance of defects in this section of track was not successful in preventing the defects from re-occurring.
The similarities between the Trim Interrupt and Flap Interrupt switches and the proximal location of the two switches unnecessarily increased the risk of mis-selection and contributed to the excessive out-of-trim condition.
Post-incident inspection of the derailment site identified a number of factors that increased the risk of a derailment in the refuge and main line. ARTC’s maintenance activities had identified some but not all of these factors prior to the derailment.
ARTC's network rules did not provide suitable guidance to assess continued safe operation when responding to track circuit faults. Additionally, the network rules permitting signals to be passed at Stop did not require a reduction in speed when the condition of the track was unknown.
The Sydney Trains worksite briefing process did not compel a new work group to seek a worksite protection pre-work briefing when accessing an existing worksite.
The worksite protection method presented an increased risk, in that track workers might inadvertently exit the worksite, and subsequently be in the immediate vicinity of operational main line rail traffic. Sydney Trains network rules and procedures for a Track Occupancy Authority did not manage the increased risk for the chosen worksite protection method.
The network rules and procedures require communications to be clear, brief and unambiguous. Network communications by various parties in Sydney Trains were not in accordance with the principles underpinning the network rules.
Sydney Trains’ work-planning process, involving multiple work groups, did not assure the consideration of worksite safety for all tasks undertaken by each involved party over the duration of the work and when returning the rail infrastructure into service.
Pacific National's training course for the loading and securing of freight, and their verification of competency checks for inspection staff, did not include the Freight Loading Manual requirements for non-standard and modified containers.
While the Freight Loading Manual was available to customers, Pacific National did not actively advise them when they had a responsibility identified by the manual. Further, they did not have a process for ensuring that customers complied with the manual’s requirements.
The ship’s manager’s (Yang Ming) cargo-planning process ashore did not ensure that the proposed container stowage plan complied with the stowage and lashing forces requirements of the ship's Cargo Securing Manual. Consequently, compliance with these requirements relied entirely on shipboard checks, made at a late stage, with limited options available for amendments without unduly impacting commercial operations.
The Cicaré 7T/B/BT mandatory service bulletin (BSC007) for the general stabiliser support assembly provided limited guidance for disassembly of the manufactured component and did not stipulate a compliance period within which to perform the inspection nor provide consideration for repeat inspections. This potentially reduced the opportunity to detect the presence of crack initiation and growth in the stabiliser support assembly.
The rostering of the driver in the days leading up to the incident was inconsistent with Sydney Trains' rostering principles.
Sydney Trains' risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances where the presence of an intermediate train stop at Richmond may have reduced the risk of trains approaching the station at excessive speed.
Sydney Trains’ risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when there were deficiencies in the buffer stop design at Richmond and at other locations.
