NSW Trains did not have systems in place to achieve outcomes in emergency response training consistent with its competency framework for passenger services crew.
The balloon manufacturer did not have an adequate process to verify the accuracy of the temperature recorded during production inflation tests.
Regulatory requirements did not ensure that aircraft lighting was adequate to conduct night vision imaging system winching operations safely.
Although the operator’s procedures for winching and night vision imaging system operations included the need to have adequate hover references and a method of recovery in the event of a night vision goggle failure, there was limited guidance to ensure these requirements were confirmed by the flight crew on‑site before commencing precision hover operations.
Toll recency for night vision imaging system (NVIS) winching was insufficient to ensure that complex NVIS winching operations, such as in this occurrence, could be conducted safely.
The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height.
In 2004, the Department of Transport and Regional Services did not have an agreed assurance framework with the Civil Aviation Safety Authority for assessing the safety information in draft major development plans. This increased the risk of plans being approved with incorrect dimensions for runway facilities and obstacle limitation surfaces.
ARTC could not reliably determine the risk of flooding along the Telarah to Acacia Ridge corridor or the risks associated with inadequate capacity cross drainage systems.
Although ARTC had procedures in place for monitoring and responding to extreme weather events, the process had significant limitations including:
The weather alerts issued by the EWN did not reliably reflect the data and frequency of ARTC’s extreme weather monitoring procedure or the service agreement. This and the services ARTC believed were included in the service agreement likely impacted the expectations of ARTC users who relied on these warnings to inform their response.
ARTC had not undertaken formal assessments to determine the need for or the locations of remote weather monitoring stations to detect extreme weather events that could affect the integrity of its rail infrastructure.
Neither ARTC or PN provided guidance for train crew to respond to extreme wet weather events or floodwater in the rail corridor. There was no guidance for when trains should stop or report if there was water on the track formation, covering the ballast, sleepers or the rail.
Response by Australian Rail Track Corporation (ARTC)
The design of the modular cabin mount was not resilient to frontal impact forces in the event of a collision. This increased the risk of their failure and separation of the cabin, removing the effectiveness of protection afforded by the collision posts.
The Rail Industry Safety and Standards Board did not provide design and/or performance standards on modular cabin resilience and retention for locomotive crashworthiness.
The procedure for predeparture testing, as part of the coupling procedure, required two competent staff. There was no procedure in the operations manual to ensure that a competent and qualified person was present to assist the driver.
The ATSB recommends that Eastern Air Link address the safety issue, through provision of guidance and training to flight crew concerning the safest option in the selection of an approach method when weather conditions are marginal for the conduct of a visual approach.
The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions.
The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions. Using this approach method, rather than a straight in instrument approach, significantly reduced obstacle clearance assurance for both an approach and any potential missed approaches, and also increased the risk to both the operator’s and other aircraft through the use of a non-standard circuit procedure.
