Although operating instructions OI 17-11 (5 April 2017) and then OI 18-72 (3 November 2018) contained a safety-critical action (to apply the automatic brake handle to the pneumatic emergency position), BHP did not clearly communicate the importance and reasons for the safety-critical action to drivers, reducing the potential for the drivers to correctly recall this procedural action.
The task of responding to brake pipe emergencies or penalties relied extensively on a driver’s memory, with limited processes in place to facilitate or cross-check a driver’s performance to ensure all safety-critical actions were completed.
Although BHP’s risk assessment for a rail-mounted equipment interaction incident identified numerous causes and critical controls for such an incident, it was broad in scope and had limited focus on the causes and critical controls for a train runaway event. In addition, the risk assessment did not include the procedure for responding to brake pipe emergencies and penalties as a critical control and BHP’s material risk control assessments (MRCAs) did not test the effectiveness of this procedural control for preventing an uncommanded movement of a train during main line operations.
The Lido airport operational information did not include the Australian Aeronautical Information Publication (AIP) advice to fit pitot probe covers at Brisbane Airport (related to significant mud wasp activity), as well as other safety AIP information.
Malaysia Airlines’ processes for the management of change did not follow recommended industry practices, and its risk and change management processes were not detailed and clear enough to assure:
Malaysia Airlines did not develop and disseminate guidance and procedures about the use of pitot probe covers to flight crews and engineers, and there was limited awareness among those groups of the need for pitot probe covers at Brisbane Airport.
Malaysia Airlines did not clearly specify the division of engineering responsibilities between Malaysia Airlines and Aircraft Maintenance Services Australia engineers at Brisbane, leading to ambiguity with regard to who should conduct the final walk-around portion of the transit check. This risk was increased by the operator commencing and continuing flights to Brisbane with interim ground handling and engineering arrangements that varied from
Malaysia Airlines flight crew and engineers did not fully complete the required aircraft inspections.
Menzies Aviation staff did not consistently carry out the required arrival and pre-departure aircraft checks of Malaysia Airlines aircraft, and Menzies Aviation audit processes were not effective at evaluating compliance with these requirements.
Aircraft Maintenance Services Australia did not have a reliable method to account for tooling and equipment (such as pitot probe covers) prior to aircraft dispatch when providing non-certifying engineering support.
Some Aircraft Maintenance Services Australia (AMSA) engineers extended the use of pitot probe covers (to mitigate the threat of wasp infestation) to operators that did not explicitly require it, including Malaysia Airlines. This increased the likelihood of error associated with the use of pitot probe covers was because AMSA engineers were not controlling or conducting all of the engineering activities and were not permitted to make technical log entries.
Although suitable for use in most situations, the streamers attached to the pitot probe covers supplied and used for A330 operations by Aircraft Maintenance Services Australia provided limited conspicuity due to their overall length, position above eye height, and limited movement in wind. This reduced the likelihood of incidental detection of the covers, which is important during turnarounds.
In the Airbus A330, there was no auditory alert associated with nil or unreliable airspeed from two or more sources during take-off (a high workload, critical phase of flight). Comparatively, other critical failures provide both visual and auditory indications.
The Airbus guidance provided in the flight crew techniques manual and other manuals for helping A330 flight crews decide whether to continue or reject a take-off did not refer to unreliable airspeed indications.
During the manufacture of the apex pin, the initial machined profile led to unintended stress concentrations at the quench stage of the material heat treatment process that resulted in the part cracking. The crack was not removed by the final machining process.
The Civil Aviation Safety Authority’s acquittal process for repeat safety findings was not effective in ensuring that all previous findings of a similar nature were also appropriately assessed prior to the current and all associated safety findings being acquitted.
Airlines of Tasmania's safety management processes for identifying hazards extensively relied on safety reports. This limited the opportunity to proactively identify the risks in all operational activities, and assess the effectiveness of any controls in place.
Airlines of Tasmania did not provide any documented guidance for the south-west operations, despite encouraging pilots to commence the flight, even when forecasts indicated they may be likely to encounter adverse weather en route. This resulted in the pilots having varied understanding of the expectations regarding in‑flight weather‑related decision making at the Arthur Range saddle, and increased the risk that some pilots continued into an area of high terrain in marginal conditions, where options to escape were limited.
There were inconsistences with Sydney Trains’ application of their fatigue management system, in particular the the use of a bio-mathematical model to predict individual fatigue risk. (Safety issue)
Sydney Trains did not provide supervision at Granville signal box to ensure there was adequate coverage on both signalling panels. (Safety issue)
