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.
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.
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 ship’s safety management system did not contain procedures or guidance on the proper use of GPS route plans and their relationship to the ship’s passage plans.
In the 30 minutes leading up to the grounding, there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater dangers directly ahead of the ship.
At the time of the grounding, the protections afforded by some of the measures currently employed in the more northern sections of the GBR were not in place in the sea area off Gladstone.
There was no effective fatigue management system in place to ensure that the bridge watch keeper was fit to stand a navigational watch after the loading in Gladstone.
The communications equipment available to the Supervisor (Excavators) was inadequate to effectively communicate with the Supervisor (Track Machines) and with the drivers of the track mounted excavators between Darrine and Jaurdi.
