Pacific National had limited controls for managing the risk of signals passed at danger during driver only operations, including incidents associated with driver fatigue. The safety system relied on a single driver correctly observing and responding to signals at all times, including during the window of the circadian low (when fatigue risk is greatest).
Pacific National's fatigue management procedures required train drivers to not work if they felt fatigued. This requirement primarily relied on drivers self-reporting if they felt fatigued, and there was no proactive assurance that drivers had obtained adequate sleep, including for higher fatigue risk situations. Self-reporting mechanisms were very seldom utilised and Pacific National had not conducted surveys or used other audit mechanisms or processes to identify any perceived or actual barriers to drivers self-identifying fatigue.
Pacific National’s rostering and fatigue management system used the FAID biomathematical model of fatigue to assess the fatigue risks associated with train driver rosters, applying a threshold FAID score of 80 for driver only operations and 100 for other operations. The operator had not conducted analysis to determine that train drivers working rosters according to these thresholds were sufficiently rested to conduct driving duties.
Qube’s operational procedure for train management between Moss Vale and Inner Harbour did not account for locomotive configurations that maintained locomotive dynamic braking during emergency applications. This increased the risk of the train driver avoiding the use of the emergency brake during a runaway event.
The assumptions regarding locomotive configurations that cut-out locomotive dynamic braking during emergency applications was found embedded in other rollingstock operator’s procedures with similarly configured locomotives in NSW.
The Civil Aviation Safety Authority's Part 133 (air transport - rotorcraft) exposition requirements did not adequately address the risk to passenger safety from a visual flight rules inadvertent instrument meteorological conditions event.
CASA response
On 21 November 2023, the Civil Aviation Safety Authority advised the ATSB that:
The Microflite air transport operations risk assessment for poor weather conditions did not consider the risk controls required for inadvertent instrument meteorological conditions. Rather, it relied on their pilots using the actual or forecast conditions to cancel their operations to manage the threat of poor weather.
Microflite did not provide, nor require, their pilots to complete a pre-flight risk assessment for their taskings. A pre-flight risk assessment would have provided pre‑defined criteria to ensure consistent and objective decision-making and reduced the risk of them selecting an inappropriate route.
Microflite had not published an inadvertent instrument meteorological conditions (IIMC) recovery procedure for their day visual flight rules pilots and their IIMC recovery training was not mandatory. The provision of this procedure and training would have reduced the risk of a loss of attitude control following an IIMC encounter.
The Microflite Operator Proficiency Checks did not include a mandatory instrument flight component for their day visual flight rules pilots. This would have reduced the risk of a loss of control event following an inadvertent instrument meteorological conditions encounter.
The operator's hazard and risk register, which formed part of the organisation's safety management system, did not identify inadvertent entry into instrument meteorological conditions as a hazard, which reduced the ability of the organisation to effectively manage the related risk.
Network pre-start briefings are a critical control in place to manage the risk of collisions between rail traffic and workers and machinery, and Queensland Rail had undertaken significant work to improve these processes. However, the design of the first-line assurance activities and the limited conduct of second-line and third-line assurance activities provided only limited assurance that the worksite protection aspects of the briefings were being conducted effectively.
The Queensland Network Rules and Procedures did not provide sufficient guidance for rail safety workers to ensure they used standardised rail-specific terminology when communicating safety-critical information.
The training provider, contracted by the operator to conduct Boeing 737 conversion training, was training pilots to flare at 30 ft rather than the manufacturer’s requirement of 20 ft. This increased the risk of unstable and/or hard landings.
The Australian Antarctic Division's pre-charter due diligence arrangements were ineffective at accurately assessing the suitability and level of preparedness of MPV Everest, its crew and its safety management system for operations in Antarctica.
MPV Everest's safety management system (SMS) was neither sufficiently mature for its operations nor had it been implemented effectively or consistently on board the ship at the time of the fire. Further, safety oversight by Fox Offshore, the ship’s managers, had not been effective in monitoring and ensuring compliance with the SMS.
MPV Everest’s managers at the time of the fire, Fox Offshore, had not ensured that the ship was adequately manned, equipped or prepared for the hazards of operations in the Southern Ocean and Antarctica.
Bureau Veritas’ (the classification society responsible) design approval processes had not identified any potential risks associated with the positioning of the fuel oil settling tank air vent pipe termination within MPV Everest's engine room ventilation casing. Consequently, it approved this design and siting of the air vent pipe that, in concert with other contributing factors, resulted in overflowing fuel from the pipe being directly introduced into the ship’s machinery spaces.
Inconsistent, incorrect or missing information related to aspects of MPV Everest’s water mist fixed fire-extinguishing system, including the spaces covered by the system and its design/operation, in multiple ship’s documents increased the risk of the crew incorrectly responding to a fire.
The engine room water mist fixed fire-extinguishing system on board MPV Everest was incorrectly installed. This increased the risk of an ineffective response in the event of a bilge fire.
