The hazard associated with the inability to separate aircraft that are below the appropriate lowest safe altitude at night was identified but not adequately mitigated. This resulted in a situation where, in the event of a simultaneous go-around at night during land and hold short operations at Melbourne Airport, there was no safe option available to air traffic controllers to establish a separation standard when aircraft were below minimum vector altitude.
The current legislation does not require commercial operators of aircraft not greater than 5,700 kg maximum take-off weight to provide instructions and procedures for crosschecking the quantity of fuel on board before and/or during flight. This increases the risk that operators in this category will not implement effective fuel policies and training to prevent fuel exhaustion events.
The presence of the earlier design of yoke on wagon NGKF 35898X was not detected during preventative maintenance activities.
The processes for monitoring the condition of the brushless exciter units’ electrical insulation were ineffective in detecting deterioration prior to unit failure.
The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to override an initial lower-priority call.
There was no network standard that directly dealt with increased derailment risk on small-radius curves.
Track geometry through the Rushall curve was not managed in accordance with Metro Trains Melbourne (MTM) network standards. A wide-gauge ‘A’ fault was not rectified in the field despite being closed-out on the asset management system.
The network’s track geometry standard did not include any specific requirement to limit a localised lateral angular discontinuity in rail line at a mechanical joint.
The network’s track geometry standards were probably unsuitable for small-radius Broad-Gauge curves. A combination of track geometry irregularities had increased the probability of flange-climb at several locations on the small-radius Rushall curve.
The positioning of the rail lubricators at this and several other locations on the network was not consistent with Metro Trains Melbourne (MTM) guidelines and probably reduced their effectiveness.
The maintenance of rail lubricators had become less effective in the months leading up to the derailment. This work was being transferred from contractors to internal Metro Trains Melbourne (MTM) staff and the transition was not adequately managed.
The Australian Transport Safety Bureau advises helicopter operators involved in overwater operations of the importance of undertaking regular HUET (helicopter underwater escape training) for all crew and regular passengers to increase their survivability in the event of an in-water accident or ditching.
Safety Advisory Notice for all helicopter operators engaged in overwater operations
The Department of Infrastructure, Regional Development and Cities adopted a prescriptive approach to the Hume City Council building application within the obstacle limitation area of Essendon Airport, which was in accordance with the process prescribed under the Airports (Protection of Airspace) Regulations 1996, but did not require the application of risk management principles to the department’s consideration.
The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.
The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.
The operator commenced regular public transport operations into Kosrae with the only instrument approach available for use being an offset procedure based on a non-precision navigation aid. The risk associated with this type of approach was amplified due to the need to use a 'dive and drive' style technique instead of a stable approach path, and that it required low level circling manoeuvring from the instrument approach to align the aircraft with the runway.
The operator's documented procedure for company personnel to report accidents and incidents was in itself not sufficient to ensure that occurrences that had affected, or had the potential to affect safety, were reported to management. This decreased the opportunity for the operator to identify potential operational risks and take appropriate action to minimise them.
Rules and procedures for detrainment do not consider a priority option of moving the train to a station or platform.
The purpose of communication between key operational people was not always clearly stated nor understood leading to misunderstandings between people.
Key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority.
