All limestone bulk hopper wagons have been operated up to 15 km/h higher than speeds specified in the Train Operating Conditions Manual, when loaded above 92 t and operated on class 1 or 1C track.
The wheel bearings on train 2224, consist BT22, were only being monitored in-service by periodic inspections, roll-bys, and hot box detections. These measures were ineffective in detecting the failure of the bearing on train 2224 before it led to the derailment.
The controller had not received training in compromised separation recovery techniques.
Ambiguity existed between the Manual of Air Traffic Services and the Aeronautical Information Publication in relation to the assignment of non-standard cruising levels and the definition of an ‘operational requirement’.
There was no evidence of any action taken by Airservices to address safety recommendations related to a review of Key Performance Indicators (KPI’s) of GAAP operations.
Moorabbin GAAP airspace design did not assure lateral or vertical strategic separation between traffic flows. This increased the risk of a mid-air collision.
The aircraft operator did not provide procedures that allowed ground handling personnel to communicate effectively with the flight crew in the event of an urgent operational matter occurring after pushback.
There was no procedure or guidance for the segregation of freight that was rejected during loading.
The Manildra Mill shunt locomotive did not have a CountryNet communication system installed as required by the New South Wales Rail Safety (General) Regulation 2008.
The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual , with the result that the pilot’s competence and ultimately, safety of the operation could not be assured.
The helicopter landing area was occasionally subjected to rapidly-moving fog or low cloud that increased the risk of flights under the visual flight rules encountering instrument meteorological conditions.
Preliminary inspections and tests of MSC Basel steering system did not identify any faults. However, more thorough examinations of the entire steering systems may identify any intermittent defects.
Rule ANWT 304 (ARTC) NWT 304 (RailCorp) does not stipulate that the Protection Officer must inform all persons or work groups who may be within the boundaries of a Track Occupancy Authority of its existence. This is regardless of whether or not these persons or work groups fit the definition of ‘work parties’ or ‘workers’.
The current TOA form (ANRF 002) does not allow the user to record details of protection measures enacted or whether all persons or work groups within the boundaries of the Track Occupancy Authority have been informed of its existence.
The NSW rules and procedures do not clearly address the requirements relating to protection of ‘out of service’ track infrastructure.
