The eTAP system, used at Track Occupancy Authority (TOA) fulfilment, did not include a key safeworking requirement contained in the ARTC Network Rule ANGE 204 for confirming and repeating back safety critical information.
ARTC will undertake a review of the relevant Rules and Procedures applicable to TOA Fulfilment being ANWT 304 and ANPR 701, including ANGE 204.
The eTAP roll out did not include an effective training regime, as the briefing was not targeted to the appropriate level of competence of the trainees. The Protection Officer involved was not trained or competent in the rules and procedures for Track Occupancy Authority (TOA) at the time of the eTAP briefing. There was no competence assessment for the use of the application for the Protection Officer involved.
Failure of the inboard programming roller cartridge was due to undetected fatigue cracking that occurred in an area that was not included in the detailed flap actuation system inspection.
On board routine inspection and maintenance of fixed cargo securing devices on APL England was ineffective. Over an extended period of time, the significant proportion of the devices that were unfit for purpose were not identified and made good.
A significant proportion of the fixed cargo securing devices on the deck of APL England were in poor condition. The heavy wastage of the devices significantly reduced their load carrying capacity and compromised the effective securing of cargo.
The insecure loading of high cube containers into bay 62 was contrary to the ship's cargo securing manual and not identifiable by the cargo computer software in use at the time. Consequently, forces generated during the heavy rolling resulted in dislodging of all containers above the cell guides and the loss of 16 overboard.
Sydney Trains Signaller refresher training, to keep signallers’ skills and knowledge up to date, has not been in place since 2009.
Sydney Trains assurance and audit processes for signal box management did not routinely detect non-conformances with NTR 432.
Sydney Trains internal safety investigation identified similar incidents i.e., where a freight train failed, that were not managed in accordance with the requirements of NTR 432, Protecting activities associated with in-service rail traffic. Recent ATSB investigations also identified examples where the requirements of NTR 432 and NPR 750 were not adequately applied.
Although an applicable height of 1,000 ft for stabilised approach criteria in instrument meteorological conditions has been widely recommended by organisations such as the International Civil Aviation Organization for over 20 years, the Civil Aviation Safety Authority had not provided formal guidance information to Australian operators regarding the content of stabilised approach criteria.
The Australian requirements for installing a terrain avoidance and warning system (TAWS) were less than those of other comparable countries for some types of small aeroplanes conducting air transport operations, and the requirements were not consistent with International Civil Aviation Organization (ICAO) standards and recommended practices. More specifically, although there was a TAWS requirement in Australia for turbine-engine aeroplanes carrying 10 or more passengers under the instrument flight rules:
Although the operator had specified a flight profile for a straight-in approaches and stabilised approach criteria in its operations manual, and encouraged the use of stabilised approaches, there were limitations with the design of these procedures.
Although the helicopter manufacturer’s instructions for continuation in service for the clutch shaft forward yoke specified that the condition of the yoke was to be inspected to verify that no cracks, corrosion, or fretting was present, it did not provide specific instructions for the method to be employed. The visual inspection that was employed increased the risk that a crack in that area may not be detected.
Aurizon did not have measuring equipment available at its Stuart Yard to identify freight loads that were outside the permissible loading profile for transport via rail.
TasRail’s processes for ensuring immediate network control actions in response to emergencies (such as runaway and authority exceedance) fundamentally relied on the experience and knowledge of network control officers and did not include the provision of procedures, tools and checklists detailed enough to support the effective management of specific types of incidents that require a time-critical response.
The guidance provided by the Office of the National Rail Safety Regulator about the requirement to submit a notification of change included limited detail about the extent or type of changes that necessitated a notification. In addition, with regard to ‘a safety critical element of rolling stock’, it did not provide detail with regard to the interpretation of ‘safety critical’ and the applicability to equipment that may not be inherently part of rolling stock (such as remote control equipment).
There was limited practical guidance specifically for the Australian rail industry for the application of system safety assurance processes to the development of complex and safety-critical rail systems.
TasRail did not have a reliable process to systematically identify, track and analyse reported faults on its remotely-controlled train or to identify their potential safety implications.
Although TasRail had a detailed change management process in place, and had documented that the project to develop the third-generation remote control equipment was a significant change, the change management process had a limited capability to:
Although there were no previous accidents attributable to TasRail’s use of remote control equipment (RCE) over 19 years, TasRail did not identify or fully assess the safety implications of remotely-controlled train operations, or those of TasRail’s specific implementation. These included the:
