NSW Trains did not have a functioning process for obtaining safety information from the ARTC web portal for its rolling stock operations within Victoria and did not routinely obtain ARTC train notices.
ARTC distribution of safety information by train notice was sub-optimal. There was scope to improve reliability of safety information distribution and to consider opportunities for operators in Victoria (and SA and WA) to receive direct distribution of train notices for their operations on the ARTC network.
For the establishment of train working arrangements that deviated from ARTC network rules, ActivateRail did not implement processes to ensure its contributions were consistent with the risk management procedures of the accredited rail infrastructure manager (ARTC) and Australian risk management standards.
For the establishment of train working arrangements that deviated from ARTC network rules, ARTC stakeholder engagement did not support its management of the safety risks to network users and the development of agreed risk controls.
For the establishment of train working arrangements that deviated from ARTC network rules, ARTC risk management and oversight processes resulted in a risk management plan that was limited in context, scope and risk identification and risk controls that had significant weaknesses.
For the routing of trains through Wallan Loop on 20 February, ARTC processes did not result in its effective engagement with network users that would be affected by this change.
NSW Trains did not have systems in place to achieve outcomes in emergency response training consistent with its competency framework for passenger services crew.
The balloon manufacturer did not have an adequate process to verify the accuracy of the temperature recorded during production inflation tests.
Regulatory requirements did not ensure that aircraft lighting was adequate to conduct night vision imaging system winching operations safely.
Although the operator’s procedures for winching and night vision imaging system operations included the need to have adequate hover references and a method of recovery in the event of a night vision goggle failure, there was limited guidance to ensure these requirements were confirmed by the flight crew on‑site before commencing precision hover operations.
Toll recency for night vision imaging system (NVIS) winching was insufficient to ensure that complex NVIS winching operations, such as in this occurrence, could be conducted safely.
The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height.
In 2004, the Department of Transport and Regional Services did not have an agreed assurance framework with the Civil Aviation Safety Authority for assessing the safety information in draft major development plans. This increased the risk of plans being approved with incorrect dimensions for runway facilities and obstacle limitation surfaces.
ARTC could not reliably determine the risk of flooding along the Telarah to Acacia Ridge corridor or the risks associated with inadequate capacity cross drainage systems.
Although ARTC had procedures in place for monitoring and responding to extreme weather events, the process had significant limitations including:
The weather alerts issued by the EWN did not reliably reflect the data and frequency of ARTC’s extreme weather monitoring procedure or the service agreement. This and the services ARTC believed were included in the service agreement likely impacted the expectations of ARTC users who relied on these warnings to inform their response.
ARTC had not undertaken formal assessments to determine the need for or the locations of remote weather monitoring stations to detect extreme weather events that could affect the integrity of its rail infrastructure.
