The ship’s pilot transfer procedures did not specify a requirement for additional crew members to assist the supervising officer. As a result, the supervising officer was actively involved in deploying the pilot ladder and manropes, and transferring the pilot’s belongings to the launch, and could not focus his efforts on properly checking the arrangements and supervising the transfer.
The pilotage company’s procedures for positive communication of readiness between the pilot and the launch crew were adequate. However, it was common for employees to vary these communication protocols, leaving perceptions of readiness open to error and misinterpretation.
The operator’s procedures did not require the flight crew to specifically check the active auto-flight mode during descent, and allowed the crew to select the Vertical Intercept Point altitude when cleared for the approach by air traffic control. This combination of procedures provided limited protection against descent through an instrument approach procedure’s segment minimum safe altitudes.
The ATSB investigation was unable to substantiate the reported observations of the train crew without having an independent source of data, such as forward facing video on train 5BM7.
The condensate drainage pots fitted to Nireas’ main air receivers were not fit for purpose as they were not capable of withstanding the internal pressures that were likely to accumulate in service.
Airservices Australia’s processes for selecting and preparing personnel for the Contingency Response Manager role did not ensure they could effectively perform that role.
Airservices Australia’s processes for reviewing and testing contingency plans did not effectively ensure that all documented contingency plan details were current and that its contingency plans could be successfully implemented at short notice.
Airservices Australia did not have a defined process for recording the actual hours worked by its Air Traffic Control Line Managers and therefore could not accurately monitor the potential fatigue of those personnel when they were performing operational roles such as a Shift Manager or Contingency Response Manager.
Airservices Australia’s processes for managing a Temporary Restricted Area did not effectively ensure that all aircraft operating in the Temporary Restricted Area were known to air traffic services.
The two JRA-776-1 fuselage lateral tie rods fitted to de Havilland DH82A Tiger Moth, registered VH-TSG, had significant, pre-existing fatigue cracks in the threaded sections. The parts’ service life was significantly less than the published retirement life for DH82A tie rods of 2,000 flight hours or 18 years).
The minimal clearance from obstructions, unfavourable surface conditions and a lack of appropriate wind indication at the helicopter landing site (HLS) increased the risk associated with operations to the HLS, particularly for a pilot unfamiliar with the site.
The pilot was assigned to a task for which he most likely lacked experience on both the helicopter type and the nature of the flying.
On the southern approach to the level crossing, the Stop Sign Ahead (W3-1) warning sign was not located in accordance with the requirements of AS 1742.7-2007 standard.
The boundary fence between the railway maintenance access track and Gallagher Road had been removed. As a result, over time and with regular use, the false perception that the maintenance access track was part of Gallagher Road was created and reinforced.
At the time of the occurrence there was limited advisory material available to owners, operators and maintenance personnel to alert them to the possibility of MS21042 nut failure and to assist with appropriately detailed inspections aimed at identifying affected items.
The nut manufacturer’s production control and quality control processes failed to prevent the release of one or more lots of MS21042L-4 nuts that remained in a partially-embrittled state after cadmium electroplating.
Poor wheel/rail adhesion was not recognised as a risk in any of Queensland Rail’s risk registers and therefore this risk to the safety of rail operations was not being actively managed.
The successful management of an emergency event from a remote location is critically dependent on clear and effective communication protocols. Communications within train control, and between train control and Cleveland station, were not sufficiently coordinated and resulted in misunderstandings at the Cleveland station accident site.
Despite numerous occurrences of slip-slide events in the years leading up to the accident at Cleveland, Queensland Rail’s risk management processes did not precipitate a broad, cross-divisional, consideration of solutions to the issue including an investigation of the factors relating to poor wheel/rail adhesion.
The Queensland Rail driver’s manual did not explain the effects of low adhesion at the wheel/rail interface, how low adhesion is a precursor to prolonged wheel slide events and why these elements reduce the likelihood of achieving expected braking rates.
