Electrical enclosures in MPV Everest's engine rooms allowed the ingress of fuel into the enclosures and did not meet the responsible classification society fluid ingress protection standards intended to reduce the associated risk of harmful effects and damage.
While fire drills conducted on board MPV Everest exceeded the minimum number required by regulations, none practised an engine room fire, nor was there was any evidence of onboard training and instruction being provided in the use of the engine room water mist fixed fire‑extinguishing system. Consequently, several crew members were unfamiliar with the operation of the system and opportunities to evaluate the ship's emergency preparedness and remedy areas in need of improvement were lost.
Helibrook’s approved safety management system was not being used to systematically identify and manage operational hazards. As a result, risks associated with conducting human external cargo operations such as carriage of the egg collector above a survivable fall height were not adequately addressed.
Response by Helibrook
The Civil Aviation Safety Authority (CASA) did not have an effective process for assuring an authorisation would be unlikely to have an adverse effect on safety. As a result, CASA delegates did not use the available structured risk management process to identify and assess the risks, ensure appropriate and adequate mitigations were included as conditions of the approval, or assess the effects of changes on the overall risk.
There was no formal interface agreement between Queensland Rail and the Brisbane City Council to jointly identify and manage ongoing and changing safety risks at the road and rail Interface.
Queensland Rail had insufficient resources available to assess all 1,138 public level crossings at 5 yearly intervals or sooner as required by its level crossing safety Standard, with only one person qualified to conduct level crossing safety assessments.
Although Queensland Rail’s internal standard required safety assessments of each public level crossing at least every 5 years, there had been no review or assessment of the Kianawah Road and other level crossings since 2001–2002.
Contrary to the relevant Australian Standard, there was a 3.1 m gap between the tip of the lowered boom barrier and the median island on the northern side of the Kianawah Road level crossing. With the turn line markings directing traffic towards the gap, this increased the risk of road users turning right from Lindum Road and bypassing the boom barrier while it was active.
The design of the horizontal stabiliser bungs did not consider aspects that would ensure the identification of an installed bung, or the safe operation of the aircraft if the bungs were not removed prior to flight.
There were no formal procedures for the storage and accountability of horizontal stabiliser bungs after they were removed from the aircraft.
Airservices Australia’s compromised separation recovery training for Sydney tower controllers did not include scenarios involving aircraft below the minimum vector altitude at night.
Airservices Australia did not have procedural controls to separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport while below the minimum vector altitude at night.
Although Airservices Australia applied operational risk assessments to high-level threats, it did not formally assess and manage the risk of specific threat scenarios. As a likely result, Airservices did not formally identify and risk manage the threat of separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport, even though it had been a known issue among controllers generally.
The Airservices Australia MARUB SIX standard instrument departure and the missed approach procedure for runway 34R directed aircraft onto outbound tracks that did not sufficiently assure separation between aircraft following the procedures concurrently.
NSW Trains’ training of passenger services crew did not include periodic simulated exercises that would allow crew members to demonstrate and maintain the knowledge and skills required in an emergency.
NSW Trains’ procedures did not provide specific instructions to passenger services crew on when, how and what to communicate to passengers in an emergency.
NSW Trains’ methods of providing safety information to passengers (including verbal safety briefings, onboard guides and signage) did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency.
Contemporary Australian industry rail standards did not include requirements for ground-level access to or egress from driver's cabs in the event of a rollover.
Contemporary Australian industry rail standards did not include structural requirements for cab doors, or other performance-based requirements, that addressed the protection of train crew in the case of vehicle overturn.
NSW Trains did not have a functioning system to monitor that drivers starting their shift at Junee received and had understood distributed safety information.
