Mimasaka’s cargo securing manual did not contain any information relating to the stowage and securing of timber veneer.
The scheduled maintenance requirements for ex-military UH-1 series helicopters may not adequately address the increased risk of fatigue failures associated with repetitive heavy lifting operations that were not considered in the original design fatigue calculations.
There was no documented evidence that Pacific National actively manages the risk of looseness and fretting damage to bearing components
The conflicting requirements and definitions in the operator’s publications in relation to the pilot not flying role had the potential to diminish the importance of monitoring as an essential element in an aircraft’s safe operation.
There was no correlation between the results of the operator’s Flight Operational Quality Assurance and Air Safety Incident Report investigations.
There were no soft and hard triggers in the operator’s Flight Operational Quality Assurance system to monitor the selection of the aircraft’s landing gear during an approach.
Public Transport Services procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.
There are inconsistencies between Right of Way procedures used by platform coordinators and passenger service attendants.
Public Transport Services driver training does not adequately address the risk of distraction and areas of human performance error with respect to SPAD events.
SPAD Investigation Form (RS-ADL-283) used by Public Transport Services does not collect data on many of the human factor issues that would facilitate a better understanding of why SPADs are occurring.
Public Transport Services do not have a formal fatigue policy/procedure.
Public Transport Services have not implemented simulator training or a similar interactive system which would allow new drivers to practice, retain and apply what they have learned without the risks associated with driving trains in traffic.
There are inconsistencies between Right of Way Work Instructions and the Common General Operating Rules.
As a defence against driver error Public Transport Services provide their railcars with a vigilance system comprising a deadman’s control and an Automatic Warning System. However, the current system does not protect against ‘Starting against Signal’ SPAD events as occurred at Adelaide Station.
Windshields manufactured with terminal block fittings containing polysulfide sealant (PR1829) have been shown to be predisposed to premature overheating failure that could lead to the development of a localised fire.
Examination of RailBAM® data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, inspection of the data showed that there was a growing/trending problem with the 2L axle-box.
An examination of wheel impact (WILD) data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, running a trend analysis of WILD data clearly showed that there was a growing wheel impact problem.
