The section of track where train 6MB2 derailed, was previously utilised as the Tottenham standard gauge passing loop. It was not stress tested after slewing and welding when it was converted to mainline operation on 28 July 2008, 5 months before the derailment.
Regular monitoring and accurate measurement of rail creep was not carried out at the east end of the curve where train 6MB2 derailed in accordance with Civil Engineering Circular 3/87 - 70.2 and 70.3. Creep monuments were not installed on the east end of the curve following the work to convert the passing loop track to mainline operation in July 2008.
The pilotage system used by Atlantic Blue’s pilot did not define off-track limits or make effective use of recognised bridge resource management tools in accordance with the Queensland Coastal Pilotage Safety Management Code and regular assessments of his procedures and practices under the code’s check pilot regime conducted over a number of years had not resolved these inconsistencies.
Atlantic Blue’s safety management system procedures did not require specific off-track limits to be included in the passage plan or otherwise ensure that limits for effective track monitoring were always defined.
The REEFVTS monitoring system did not provide an ‘exiting corridor alarm’ when Atlantic Blue exited the two-way route that it was transiting because the route had not been defined as a navigational corridor.
The ‘shallow water alert’ generated by the Great Barrier Reef and Torres Strait Vessel Traffic Service’s (REEFVTS) monitoring system did not provide adequate warning of Atlantic Blue entering shallow water because the boundary of the defined shallow water alert area was too close to dangers off Kirkcaldie Reef.
Information contained in the approved flight manual and pilot's operating handbook was not applicable to the engine that was fitted to the aircraft.
While Petra Frontier had undergone an initial flag State inspection on 4 May 2009 and routine class surveys, the most recent being a class survey completed on 12 August 2009, neither authority was aware that the ship was unseaworthy in relation to critical safety equipment when it departed Singapore.
The Registered Operator's maintenance control practices did not ensure compliance with all Airworthiness Directives.
There was the potential for the incorrect use of the dipstick to result in the over-reading of the fuel quantity.
Petra Frontier’s safety management system contained procedures outlining how fire and abandon ship drills should be carried out in accordance with SOLAS and Marshall Islands requirements. However, it also contained a drill schedule that provided some contradictory information.
The United States Federal Aviation Administration regulations and associated guidance material did not fully address the potential harm to flight safety posed by liquid contamination of electrical system units in transport category aircraft.
The galley drain operation and maintenance processes did not adequately prevent blockage and overflow of the aircraft’s drain lines.
The priority level of the battery discharge messages that were provided by the engine indicating and crew alerting system did not accurately reflect the risk presented by the battery discharge status.
Maintenance processes did not identify or correct the deterioration of the drip shield.
The aircraft operator’s documented design objectives did not explicitly require the protection of non-structural systems from liquid contact or ingress.
