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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: RO-2017-014-SI-01Track maintenance Number: RO-2017-014-SI-01 Description: RO-2017-014-SI-01:There were track defects identified in the vicinity of the derailment site prior to the derailment. The maintenance of defects in this section of track was not successful in preventing the defects from re-occurring. Who it affects: All rail operators operating on ARTC track Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Infrastructure	Date, status, type Date: 26 May 2020 Status: Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2019-019-SI-01 Pilatus PC-12 trim and flap interrupt switches Number: AO-2019-019-SI-01 Description: AO-2019-019-SI-01 :The similarities between the Trim Interrupt and Flap Interrupt switches and the proximal location of the two switches unnecessarily increased the risk of mis-selection and contributed to the excessive out-of-trim condition. Who it affects: Operators and pilots of PC-12 aircraft Issue owner: Pilatus Aircraft Ltd Operation affected: Aviation: General aviation	Date, status, type Date: 13 May 2020 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2019-010-SI-02ARTC Track infrastructure activities Number: RO-2019-010-SI-02 Description: RO-2019-010-SI-02:Post-incident inspection of the derailment site identified a number of factors that increased the risk of a derailment in the refuge and main line. ARTC’s maintenance activities had identified some but not all of these factors prior to the derailment. Who it affects: All owners and operators of rail networks Issue owner: Australian Rail Track Corporation Operation affected: Rail: Infrastructure	Date, status, type Date: 07 May 2020 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: RO-2019-010-SI-03 ARTC Network rules and procedures Number: RO-2019-010-SI-03 Description: RO-2019-010-SI-03 :ARTC's network rules did not provide suitable guidance to assess continued safe operation when responding to track circuit faults. Additionally, the network rules permitting signals to be passed at Stop did not require a reduction in speed when the condition of the track was unknown. Who it affects: All owners and operators of rail networks track circuits Issue owner: Australian Rail Track Corporation Operation affected: Rail: Infrastructure	Date, status, type Date: 07 May 2020 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-008-SI-04Worksite protection pre-work briefing Number: RO-2016-008-SI-04 Description: RO-2016-008-SI-04:The Sydney Trains worksite briefing process did not compel a new work group to seek a worksite protection pre-work briefing when accessing an existing worksite. Who it affects: Sydney Trains track work Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 20 Apr 2020 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-008-SI-03TOA limitations Number: RO-2016-008-SI-03 Description: RO-2016-008-SI-03:The worksite protection method presented an increased risk, in that track workers might inadvertently exit the worksite, and subsequently be in the immediate vicinity of operational main line rail traffic. Sydney Trains network rules and procedures for a Track Occupancy Authority did not manage the increased risk for the chosen ... Who it affects: Sydney Trains track work Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 20 Apr 2020 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-008-SI-02Network Communications Number: RO-2016-008-SI-02 Description: RO-2016-008-SI-02:The network rules and procedures require communications to be clear, brief and unambiguous. Network communications by various parties in Sydney Trains were not in accordance with the principles underpinning the network rules.   Who it affects: Sydney Trains track work Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 20 Apr 2020 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-008-SI-01Work-planning process and multiple work groups Number: RO-2016-008-SI-01 Description: RO-2016-008-SI-01:Sydney Trains’ work-planning process, involving multiple work groups, did not assure the consideration of worksite safety for all tasks undertaken by each involved party over the duration of the work and when returning the rail infrastructure into service. Who it affects: Sydney Trains track work Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 20 Apr 2020 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-010-SI-02Education on loading and inspection of modified containers Number: RO-2018-010-SI-02 Description: RO-2018-010-SI-02:Pacific National's training course for the loading and securing of freight, and their verification of competency checks for inspection staff, did not include the Freight Loading Manual requirements for non-standard and modified containers. Who it affects: Pacific National inspection staff Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 31 Mar 2020 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-010-SI-01Advise relevant external parties of container loading requirements and check for compliance Number: RO-2018-010-SI-01 Description: RO-2018-010-SI-01:While the Freight Loading Manual was available to customers, Pacific National did not actively advise them when they had a responsibility identified by the manual. Further, they did not have a process for ensuring that customers complied with the manual’s requirements. Who it affects: Pacific National and relevant external parties (customers) Issue owner: Pacific National Pty Ltd Operation affected: Rail: Passenger - regional	Date, status, type Date: 31 Mar 2020 Status: Adequately addressed Type: Safety Advisory Notice
Issue, description, who it affects Issue: MO-2018-008-SI-01 Shore planning Number: MO-2018-008-SI-01 Description: MO-2018-008-SI-01 :The ship’s manager’s (Yang Ming) cargo-planning process ashore did not ensure that the proposed container stowage plan complied with the stowage and lashing forces requirements of the ship's Cargo Securing Manual. Consequently, compliance with these requirements relied entirely on shipboard checks, made at a late stage, with limited options available ... Who it affects: Ships operated by Yang Ming Issue owner: Yang Ming Marine Transport Corporation Operation affected: Marine: Shipboard operations	Date, status, type Date: 13 Feb 2020 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2015-089-SI-01 Cicaré S.A. CH-7T/B/BT service bulletin Number: AO-2015-089-SI-01 Description: AO-2015-089-SI-01 :The Cicaré 7T/B/BT mandatory service bulletin (BSC007) for the general stabiliser support assembly provided limited guidance for disassembly of the manufactured component and did not stipulate a compliance period within which to perform the inspection nor provide consideration for repeat inspections. This potentially reduced the opportunity to detect the presence ... Who it affects: All owners and operators of Cicaré CH7T/B/BT helicopters Issue owner: Cicaré S.A. Operation affected: Aviation: General aviation	Date, status, type Date: 20 Dec 2019 Status: Adequately addressed Type: Proactive Action   Proactive Action   Safety Advisory Notice
Issue, description, who it affects Issue: RO-2018-004-SI-05Rostering of the driver inconsistent with rostering principles Number: RO-2018-004-SI-05 Description: RO-2018-004-SI-05:The rostering of the driver in the days leading up to the incident was inconsistent with Sydney Trains' rostering principles. Who it affects: Rail rostering managers Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 20 Dec 2019 Status: Not addressed Type: Recommendation
Issue, description, who it affects Issue: RO-2018-004-SI-04Management of risk associated with intermediate train stop installation Number: RO-2018-004-SI-04 Description: RO-2018-004-SI-04:Sydney Trains risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances where the presence of an intermediate train stop at Richmond may have reduced the risk of trains approaching the station at excessive speed. Who it affects: Rail infrastructure managers Issue owner: Sydney Trains Operation affected: Rail: Infrastructure	Date, status, type Date: 20 Dec 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-004-SI-03Management of risk associated with buffer stop deficiencies Number: RO-2018-004-SI-03 Description: RO-2018-004-SI-03:Sydney Trains’ risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when there were deficiencies in the buffer stop design at Richmond and at other locations. Who it affects: Rail infrastructure managers Issue owner: Sydney Trains Operation affected: Rail: Infrastructure	Date, status, type Date: 20 Dec 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-004-SI-02Buffer stop effectiveness in collision Number: RO-2018-004-SI-02 Description: RO-2018-004-SI-02:When A42 collided with buffer stop at Richmond station No. 2 platform the reinforced concrete end stop of the buffer stop withstood the impact of the collision and prevented the train from crossing into a pedestrian and main road precinct. The two hydro-pneumatic rams on the front of the buffer ... Who it affects: Rail infrastructure managers Issue owner: Sydney Trains Operation affected: Rail: Infrastructure	Date, status, type Date: 20 Dec 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-004-SI-01Crash energy management system did not perform as designed Number: RO-2018-004-SI-01 Description: RO-2018-004-SI-01:The crash energy management system on the Waratah passenger train A42 reduced the impact force of the collision but not all components performed as designed. The performance of the crash energy management system was significantly limited by the buffer stop at Richmond being incompatible with the front of the Waratah ... Who it affects: Rolling stock designers and rail infrastructure managers Issue owner: Downer Operation affected: Rail: Rolling stock	Date, status, type Date: 20 Dec 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-098-SI-01Passenger oxygen mask instructions Number: AO-2017-098-SI-01 Description: AO-2017-098-SI-01:The pre-flight safety briefing and safety information card did not include a clear instruction on how to activate the flow of oxygen from the passenger oxygen masks and that the bag may not inflate when oxygen is flowing. This resulted in some passengers not understanding whether or not there was ... Who it affects: Airline passengers Issue owner: AirAsia Indonesia Operation affected: Aviation: Air transport	Date, status, type Date: 26 Nov 2019 Status: Not addressed Type: Recommendation
Issue, description, who it affects Issue: AO-2017-013-SI-01Air display approval and oversight Number: AO-2017-013-SI-01 Description: AO-2017-013-SI-01:The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors: While the Air Display Manual provided guidance to organisers conducting an air display, it did not inherently provide the processes and tools needed for CASA to approve ... Who it affects: Air displays: Organisers and participants in air displays Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Other	Date, status, type Date: 19 Nov 2019 Status: Safety action pending Type: Proactive Action   Recommendation
Issue, description, who it affects Issue: MO-2017-010-SI-02Usage of tugs Number: MO-2017-010-SI-02 Description: MO-2017-010-SI-02:Tugs were to be available to escort the mini cape-size ships until they had entered the South Channel, where they were then stood down. However, the tug masters had not been trained in the specifics of escort towage nor in emergency response. Who it affects: All owners, operators and crewmembers involved in pilotage Issue owner: Ports North Operation affected: Marine: Shipboard operations	Date, status, type Date: 14 Nov 2019 Status: Adequately addressed Type: Proactive Action