Track inspections were not consistently conducted at intervals of not more than 96 hours, in accordance with TasRail’s standard.
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.
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.
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.
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 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 engine manufacturer's process for retrospective concessions did not specify when in the process the Chief Engineer and Business Quality Director approvals were to be obtained. Having them as the final approval in the process resulted in an increased probability that the fleet-wide risk assessment would not occur.
The engine manufacturer did not have a requirement for an expert review of statistical analyses used in retrospective concession applications.
The procedure for the first article inspection process contained ambiguities that resulted in an interpretation whereby the use of the manufacturing stage drawings was deemed to be acceptable.
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.
The evolution of the current advisory material relating to the minimisation of hazards resulting from uncontained engine rotor failures was based on service experience, including accident investigation findings. The damage to Airbus A380-842 VH-OQA exceeded the modelling used in the UERF safety analysis and, therefore, represents an opportunity to incorporate any lessons learned from this accident into the advisory material.
