TasRail had not instigated proactive action to manage the elevated risks associated with ongoing track stability issues at, or near, the derailment site in accordance with their maintenance procedures.
Track inspections were not consistently conducted at intervals of not more than 96 hours, in accordance with TasRail’s standard.
The twist defect was not detected by TasRail’s inspection/monitoring systems, increasing the risk of derailment.
The ARTC had not instigated proactive action to manage the increased risk of a buckling event in accordance with their procedure ETM-06-06 (Managing Track Stability – Concrete Sleepered Track) at section 1.11.5 - ‘Special Locations’.
Limited guidance was provided by the operator and Air Ambulance Victoria for to crews on the selection of the most appropriate winch rescue equipment given operational and medical considerations, and the conditions when various types of equipment should be considered.
The design cooling characteristics of the Engine Alliance GP7200 high pressure turbine (HPT) stage-2 nozzle components led to higher than expected metal surface temperatures during operation, rendering the nozzles susceptible to distress, premature degradation and failure.
The threshold limits for the engine trend monitoring program were not set at a level that provided sufficient opportunity for inspection of the engine before failure could occur from the effects of HPT stage-2 nozzle degradation.
The ARTC’s systems and operational procedures provided limited additional information or guidance to assist network control staff in identifying and assessing a potential threat to the serviceability of the infrastructure resulting from significant weather events.
ClassNK did not have in place a system which ensured that updated service advice from the engine manufacturer was being implemented on board ships with engines which its surveyors were routinely and regularly surveying.
The ship’s planned maintenance system did not include all of the main engine manufacturer’s maintenance requirements. Furthermore, the maintenance records did not include sufficient detail to confirm that the main engine was maintained in accordance with the manufacturer’s requirements.
The Civil Aviation Regulations 1988 allow class B aircraft registration holders to maintain their aircraft using the CASA maintenance schedule in situations where a more appropriate manufacturer’s maintenance schedule exists.
The Civil Aviation Regulations 1988 lack clarity regarding the requirement for aircraft manufacturers’ supplemental inspections, where available, to be carried out when an aircraft is being maintained in accordance with the CASA maintenance schedule.
West Coast Wilderness Railway had not considered all of the risks associated with the operation of road-rail vehicles on the steep railway. As a result, documented operational procedures had not been developed and locations where vehicles could be safely on/off railed had not been defined.
The Australian Transport Safety Bureau advises balloon operators to review their risk controls in relation to the safety of cold-air inflation fans, especially in relation to passenger proximity to operating fans, and the security of loose items, such as passenger clothing.
The wheel inspection processes prior to the failure of locomotive wheel L4 on SCT 008 were not effective in detecting surface damage or cracks
Subsurface cracks appeared to be more common on wheels made with Class BM grade steel while operating under conditions of high speed cyclic loading, such as the SCT class locomotives
The manufacturer’s classification, relating to the criticality of failure, of the HP/IP bearing support assembly was inappropriate for the effects of a fire within the buffer space and hence, the requirement for an appropriate level of process control was not communicated to the manufacturing staff.
The calculation method in the aircraft manufacturer’s landing distance performance application was overly conservative and this could prevent the calculation of a valid landing distance at weights below the maximum landing weight with multiple system failures.
The engine manufacturer did not require its manufacturing engineers to consult with the design engineers to ensure that design intent would be maintained when introducing manufacturing datums.
Numerous other engines within the Trent 900 fleet were also found to contain a critical reduction in the oil feed stub pipe wall thickness.
