When A42 collided with buffer stop at Richmond station No. 2 platform, the reinforced concrete end stop of the buffer stop withstood the impact of the collision and prevented the train from crossing into a pedestrian and main road precinct. The two hydro-pneumatic rams on the front of the buffer stop did not perform their intended function. They were not aligned with the front of the Waratah train and instead of absorbing energy from the collision, they penetrated the cavity either side of the front-of-train coupler.
The crash energy management system on the Waratah passenger train A42 reduced the impact force of the collision but not all components performed as designed. The performance of the crash energy management system was significantly limited by the buffer stop at Richmond being incompatible with the front of the Waratah train.
The pre-flight safety briefing and safety information card did not include a clear instruction on how to activate the flow of oxygen from the passenger oxygen masks and that the bag may not inflate when oxygen is flowing. This resulted in some passengers not understanding whether or not there was oxygen flowing in the mask.
The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors:
Tugs were to be available to escort the mini cape-size ships until they had entered the South Channel, where they were stood down. However, the tug masters had not been trained in the specifics of escort towage nor in emergency response.
In pre-trial simulations, the risks associated with engine failure during departure were only considered up to when a ship had entered the South Channel. Consequently, the tugs were not in attendance to assist if propulsion was lost.
There were a total of 16 engine malfunction events globally over a 4-year period attributed to modification of the Advantage 70™ engine. The modification increased the engine outer duct gas path temperature, which led to distortion and liberation of the outer transition duct segments.
Response by Pratt and Whitney (P & W)
The fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform the equipment would not have worked correctly, resulting in serious or fatal injuries.
The Civil Aviation Advisory Publication for Aeroplane Landing Areas (92-1(1)) did not have guidance for the inclusion of a safe runway overrun area.
The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.
There was no requirement for operators of passenger transport flights in aircraft with six or less seats to provide passengers with a verbal briefing, or written briefing material, on the brace position for an emergency landing or ditching, even for aircraft without upper torso restraints fitted to all passenger seats.
Upper torso restraints (UTRs) were not required for all passenger seats for small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992, including for passenger transport operations. Although options for retrofitting UTRs are available for many models of small aircraft, many of these aircraft manufactured before the applicable dates that are being used for passenger transport have not yet been retrofitted.
There were a significant number and variety of problems associated with the operator’s activities that increased safety risk, and the operator’s chief pilot held all the key positions within the operator’s organisation and conducted most of the operator’s flights. Overall, there were no effective mechanisms in place to regularly and independently review the suitability of the operator’s activities, which enabled flight operations to deviate from relevant standards.
The operator’s pilots routinely conducted near-aerobatic manoeuvres during passenger charter flights. However, procedures for these manoeuvres were not specified in the operator’s Operations Manual, and there were limited controls in place to manage the risk of these manoeuvres.
Although the operator’s procedures required that baggage and cargo be secured during flight, this procedure was routinely not followed, and the aircraft were not equipped with cargo nets or other means for securing loads in the baggage compartment.
Although the operator’s procedures required that actual weights be used for passengers, baggage and other cargo, this procedure was routinely not followed, and pilots relied on estimated weights when calculating an aircraft’s weight and balance.
The operator normally conducted airborne inspections of the Middle Island aeroplane landing area at about 50–100 ft while flying at normal cruise speed towards an area of water, and its procedures did not ensure the effective management of the risk of an engine failure or power loss when at a low height.
The wiring error was not detected by Metro Trains Melbourne’s verification program.
V/Line did not have a documented detailed process for inhibiting and reinstating level crossing protection equipment.
The Civil Aviation Safety Authority did not have a system to differentiate between community service flights and other private operations, which limited its ability to identify risks. This hindered the Civil Aviation Safety Authority's ability to manage risks associated with community service flights.
