Although a number of aerobatic manoeuvres were permitted in Tiger Moth aircraft, there was no limitation on the amount of aerobatic operations that was considered to be safe. As a result, operators may be unaware that a high aerobatic usage may exceed the original design assumptions for the aircraft.
Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life‑limits, were appropriately considered.
Together with a number of other Australian Tiger Moths, VH-TSG was fitted with non‑standard Joint H attachment bolts that did not conform to the original design with the result that the integrity of the Joint H could not be assured.
The manufacturer’s quality system did not prevent non-conforming tie rods from being released for use on aircraft.
It was likely that, because of the Civil Aviation Safety Authority’s policy at the time, their engineering assessment of the tie rod design for inclusion in the manufacturer’s Australian Parts Manufacturer Approval did not consider the service history of the original tie rods or identify that they were subject to airworthiness directive AD/DH 82/10. Consequently, the assessment team was likely unaware that the original tie rods were subject to a life limitation, and did not require the life limits for the replacement tie rods to be established.
The JRA-776-1 fuselage lateral tie rods that were inspected by the ATSB were not appropriately marked with part and serial numbers, affecting the traceability and service history of the parts in a number of aircraft.
When approving the change in material for the manufacture of the replacement tie rods, the design engineer did not identify that the original parts had a life limitation, or that they had shown susceptibility to fatigue cracking. As a result, the engineer did not compare the fatigue performance of the alternative design to the original, and the replacement tie rods were manufactured to that design and released into service with an unknown fatigue life.
The ARTC response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October.
Track patrol processes were ineffective at detecting and remedying the wide gauge defect at the derailment location. Track patrols were overly reliant on the AK Car geometry recording vehicle to trigger maintenance action on this track geometry defect.
ARTC processes for managing the condition of the rail were ineffective despite repeated recording of rail head wear by the AK Car, and local knowledge of the worn rail. The rail was worn beyond the rail condemning limits specified within the network code of practice.
When the AK Car was operating in Manual mode, the methods used to identify the location of a defect, and assist track staff to locate the defect could be ineffective in certain scenarios. At the derailment location, there was a consistent offset of about 58 m between the recorded location of the wide-gauge defect and its actual location due to the presence of a ‘long kilometre’.
The ARTC Local Appendix Unit North – Volume 3 did not reflect current equipment installation arrangements for E Frame at Singleton.
The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display.
The design of the NTCS in screening Adelaide metro broadcast communications prevented the driver of 2MP9 from gaining an appreciation of activities close to his area of operation, in particular the position of train 2MP1 along the Mile End main line.
The practice of pathing a following train onto the same line occupied by a preceding train, without pre-warning the driver regarding the train ahead, presented an elevated level of risk.
The practice of pathing a following train onto a line occupied by a preceding train, when an alternate route was available and not obstructed, presented an elevated level of risk.
Vegetation and a low fence adjacent the Mile End crossing loop partially obscured the view that the crew of train 2MP9 had of the empty flat wagons at the rear of train 2MP1.
Debris originating from the starter failure was not contained by the starter casing and severed the number one engine B-sump oil scavenge pipe.
There were no formal systems in place to manage the accepted practice of Protection Officers leaving a work site to return a Track Warrant and Train Staff, prior to ceasing works, off-tracking and ensuring the line was clear. This practice led to the informal delegation of responsibility for ensuring the track was clear to others at the work site.
The lack of an appointed Officer in Charge of the incident site prior to the arrival of an Incident Rail Commander led to a fragmented response with no single employee having a recognised leadership role on site.
