The convergence of many published air routes overhead Adelaide, combined with the convergence point being positioned on the sector boundary of the Augusta and Tailem Bend sectors, reduced the separation assurance provided by strategically separated one-way air routes and increased the potential requirement for controller intervention to assure separation.
Not all major infrastructure was marked on the ATRICS screens for the North Shore panel.
Differences exist in the way signallers and Protection Officers (POs) identify trains to each other.
Rule NWT 308 Absolute Signal Blocking and procedure NPR703 Using Absolute Signal Blocking did not provide any guidance on acceptable methods for determining the location of rail traffic in the section or confirming the clearance of rail traffic past a proposed work location.
The Sydney Trains regime for auditing worksite protection arrangements was not effective in identifying emerging trends or safety critical issues when using Absolute Signal Blocking (ASB).
There were no forms or checklists to provide practical guidance for completing the steps required to implement Absolute Signal Blocking (ASB) or to provide an auditable record of the process.
The GWA guidance does not provide clear and unambiguous information for train crews on acceptable points approach speeds where sighting distance is reduced
Union Reef was not treated as a special location as defined in the ARA Code of Practice for the Australian Rail Network.
The train crew had conflicting responsibilities distracting them from the safety critical task of driving. GWA did not have specific policies and procedures to define responsibilities of train crews approaching safety critical phases of operation.
The manufacturer’s instruction manual for Seven Seas Voyager’s waste incinerator contained no specific instructions for ash grate maintenance or replacement. Such instructions would have provided useful information for the ship’s crew to plan and safely complete periodic ash grate maintenance.
Seven Seas Voyager’s planned maintenance system (PMS) contained no information about waste incinerator ash grate replacement, a task that would have been periodically undertaken by different engineering staff since 2003. Therefore, in this respect, the shipboard procedures that documented requirements for the PMS had not been effectively implemented.
The ARTC’s inspection and maintenance practices were ineffective at identifying and correcting the deteriorating condition of track infrastructure exhibiting accelerated wear, such as 38A points at Spencer Junction.
The Train Control System permitted the NCO to set an unviable route for the train and then displayed it as viable. The train control system alarm designed to alert the NCO to the setting of an unviable route was nullified by the absence of gauge detection.
A caution order instrument was used that lacked a specific requirement for train crews to check the points along their route. This requirement becomes critical under circumstances of signalling system degradation.
The ship’s managers did not have effective systems to ensure that the defective control system for the controllable pitch propeller was reported to the relevant organisations as required.
Consequently, Brisbane’s vessel traffic services, pilotage provider and the pilot remained unaware of the defect and could not consider it in their risk assessments before the pilotage started.
The ship’s agent’s information questionnaire did not ask for all of the information required to complete the QSHIPS booking form and ensure that defects were reported.
HC Rubina’s electronic planned maintenance system did not contain any instructions to ensure that the shaft alternator flexible coupling was maintained in accordance with the manufacturer’s requirements.
All-engine go-arounds in modern air transport aircraft are often a challenging task when there is a requirement to level-off at a low altitude, and many pilots have had limited preparation for this task.
The procedures for locomotive inspection and maintenance were not effective at identifying and addressing continuing fuel leakage problems on this type of fuel filter assembly.
The company’s Required Navigation Performance approach procedure allowed the flight crew to set the approach minimum altitude in the auto-flight system prior to commencing the approach. This did not ensure the altitude alerting system reflected the assigned altitude limit of 7,000 ft and removed the defence of that alert when the flight crew did not identify the disengagement of the flight management computer-derived VNAV PTH mode.
