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Recommendations and safety advisory notices

 

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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: RO-2016-004-SI-01Preventative maintenance systems
Number: RO-2016-004-SI-01
Description: RO-2016-004-SI-01:The presence of the earlier design of yoke on wagon NGKF 35898X was not detected during preventative maintenance activities.
Who it affects: Pacific National
Issue owner: Pacific National
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Jun 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-07Train radio functionality
Number: RO-2016-002-SI-07
Description: RO-2016-002-SI-07:The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to override an initial lower-priority call.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-06Standard for derailment risk on small-radius curves
Number: RO-2016-002-SI-06
Description: RO-2016-002-SI-06:There was no network standard that directly dealt with increased derailment risk on small-radius curves.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-05Management of wide gauge defect
Number: RO-2016-002-SI-05
Description: RO-2016-002-SI-05:Track geometry through the Rushall curve was not managed in accordance with Metro Trains Melbourne (MTM) network standards. A wide-gauge ‘A’ fault was not rectified in the field despite being closed-out on the asset management system.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-02Standard for angular discontinuity at mechanical joints
Number: RO-2016-002-SI-02
Description: RO-2016-002-SI-02:The network’s track geometry standard did not include any specific requirement to limit a localised lateral angular discontinuity in rail line at a mechanical joint.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-04Track geometry standards
Number: RO-2016-002-SI-04
Description: RO-2016-002-SI-04:The network’s track geometry standards were probably unsuitable for small-radius Broad-Gauge curves. A combination of track geometry irregularities had increased the probability of flange-climb at several locations on the small-radius Rushall curve.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-03Location of rail lubricators
Number: RO-2016-002-SI-03
Description: RO-2016-002-SI-03:The positioning of the rail lubricators at this and several other locations on the network was not consistent with Metro Trains Melbourne (MTM) guidelines and probably reduced their effectiveness.
Who it affects: Rail: Passenger – metropolitan and regional
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-01Rail lubricator maintenance
Number: RO-2016-002-SI-01
Description: RO-2016-002-SI-01:The maintenance of rail lubricators had become less effective in the months leading up to the derailment. This work was being transferred from contractors to internal Metro Trains Melbourne (MTM) staff and the transition was not adequately managed.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2018-022-SAN-001Helicopter underwater escape training
Number: AO-2018-022-SAN-001
Description: AO-2018-022-SAN-001:The Australian Transport Safety Bureau advises helicopter operators involved in overwater operations of the importance of undertaking regular HUET (helicopter underwater escape training) for all crew and regular passengers to increase their survivability in the event of an in-water accident or ditching. Safety Advisory Notice for all helicopter operators engaged in ...
Who it affects: All overwater helicopter operators
Issue owner: All overwater helicopter operators
Operation affected: Aviation: Other
Date, status, type
Date: 03 May 2018
Status: Safety action pending
Issue, description, who it affects
Issue: AI-2013-102-SI-01The use of risk management principles when considering an application under the Airports (Protected Airspace) Regulations
Number: AI-2013-102-SI-01
Description: AI-2013-102-SI-01:The Department of Infrastructure, Regional Development and Cities adopted a prescriptive approach to the Hume City Council building application within the obstacle limitation area of Essendon Airport, which was in accordance with the process prescribed under the Airports (Protection of Airspace) Regulations 1996, but did not require the application of ...
Who it affects: Airports managing protected airspace associated with their runways
Issue owner: The Department of Infrastructure, Regional Development and Cities
Operation affected: Aviation: Airspace management
Date, status, type
Date: 03 May 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-105-SI-01Autopilot advice, limitations cautions and warnings (written and audible)
Number: AO-2015-105-SI-01
Description: AO-2015-105-SI-01:The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.
Who it affects: Aircraft owners and operators of aircraft fitted with the Garmin G1000 avionics system and GFC700 autopilot.
Issue owner: Cessna Aircraft Company (Textron)
Operation affected: Aviation: General aviation
Date, status, type
Date: 17 Apr 2018
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2015-105-SI-02Autopilot advice, limitations cautions and warnings (written and audible)
Number: AO-2015-105-SI-02
Description: AO-2015-105-SI-02:The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.
Who it affects: Aircraft owners and operators of aircraft fitted with the Garmin G1000 avionics system and GFC700 autopilot.
Issue owner: Garmin
Operation affected: Aviation: General aviation
Date, status, type
Date: 17 Apr 2018
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2015-066-SI-01Elevated risk from non-precision approach with low-level circling and non-stabilised approach procedure
Number: AO-2015-066-SI-01
Description: AO-2015-066-SI-01:The operator commenced regular public transport operations into Kosrae with the only instrument approach available for use being an offset procedure based on a non-precision navigation aid. The risk associated with this type of approach was amplified due to the need to use a 'dive and drive' style technique instead ...
Who it affects: Nauru Airlines
Issue owner: Nauru Airlines
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Mar 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-157-SI-01Safety reporting culture and procedures
Number: AO-2016-157-SI-01
Description: AO-2016-157-SI-01:The operator's documented procedure for company personnel to report accidents and incidents was in itself not sufficient to ensure that occurrences that had affected, or had the potential to affect safety, were reported to management. This decreased the opportunity for the operator to identify potential operational risks and take appropriate ...
Who it affects: All owners and operators of aircraft
Issue owner: Rebel Ag Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 13 Mar 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-009-SI-04Processes for evacuating trains
Number: RO-2014-009-SI-04
Description: RO-2014-009-SI-04:Rules and procedures for detrainment do not consider a priority option of moving the train to a station or platform.
Who it affects: All rail operations
Issue owner: NSW Trains; Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 17 Jan 2018
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2014-009-SI-03Unclear purpose of communication
Number: RO-2014-009-SI-03
Description: RO-2014-009-SI-03:The purpose of communication between key operational people was not always clearly stated nor understood leading to misunderstandings between people.
Who it affects: All rail operations
Issue owner: NSW Trains; Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 17 Jan 2018
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2014-009-SI-02Management of change
Number: RO-2014-009-SI-02
Description: RO-2014-009-SI-02:Key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority.
Who it affects: All rail operations
Issue owner: NSW Trains; Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 17 Jan 2018
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2014-009-SI-01Train protection
Number: RO-2014-009-SI-01
Description: RO-2014-009-SI-01:The crew of V938 detrained passengers onto the track near Kilbride without having arranged the required train protection with the ARTC Network Controller in accordance with the ARTC Network rules and procedures.
Who it affects: All rail operations
Issue owner: NSW Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 17 Jan 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-16Guidance information on the limitations of FAID
Number: AO-2014-190-SI-16
Description: AO-2014-190-SI-16:Guidance material associated with the FAID bio-mathematical model of fatigue did not provide information about the limitations of the model when applied to roster patterns involving minimal duty time or work in the previous 7 days.
Who it affects: All operators and flight crew: Air transport and general aviation
Issue owner: InterDynamics
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-15Regulatory surveillance – assessing process in practice
Number: AO-2014-190-SI-15
Description: AO-2014-190-SI-15:Consistent with widely-agreed safety science principles, the Civil Aviation Safety Authority’s approach to surveillance of larger charter operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the actual conduct of line operations (or ‘process in practice’).
Who it affects: All operators
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: Adequately addressed
Type: Proactive Action
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