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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2017-078-SI-01Maintenance practices Number: AO-2017-078-SI-01 Description: AO-2017-078-SI-01:Cloncurry Air Maintenance had adopted a number of practices, which included using abbreviated inspection checklists, not recording all flight control disturbances and not progressively certifying for every inspection item as the work was completed, which increased the risk of memory-related errors and the omission of tasks. Who it affects: Cloncurry Air Maintenance Issue owner: Cloncurry Air Maintenance Operation affected: Aviation: Maintenance	Date, status, type Date: 21 Jul 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-007-SI-04Procedures for sharing workload in two-driver operation Number: RO-2018-007-SI-04 Description: RO-2018-007-SI-04:Aurizon’s procedures and guidance for two-driver operation during situations such as a condition affecting the network (CAN) did not facilitate the effective sharing of duties and teamwork to minimise the potential effects of degraded conditions on driver workload and fatigue. Who it affects: The operator’s train crew Issue owner: Aurizon Operation affected: Rail: Freight	Date, status, type Date: 30 Jun 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2018-007-SI-03Application of a controlled speed requirement by network control Number: RO-2018-007-SI-03 Description: RO-2018-007-SI-03:Queensland Rail did not have any restrictions on the distance or time that controlled speed could be used as a risk control for safe train operation in situations such as a condition affecting the network (CAN). The effectiveness of controlled speed has the significant potential to deteriorate over extended time ... Who it affects: Network control Issue owner: Queensland Rail Operation affected: Rail: Operations control	Date, status, type Date: 30 Jun 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2018-007-SI-02Procedures for actively monitoring conditions ahead of a train Number: RO-2018-007-SI-02 Description: RO-2018-007-SI-02:Queensland Rail did not have procedures that required network control personnel to actively search for information about track conditions ahead of a train during situations such as a condition affecting the network (CAN), when conditions had the realistic potential to have deteriorated since the last patrol or train had run ... Who it affects: Network control Issue owner: Queensland Rail Operation affected: Rail: Operations control	Date, status, type Date: 30 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-007-SI-01Advice of weather monitoring station serviceability Number: RO-2018-007-SI-01 Description: RO-2018-007-SI-01:Queensland Rail did not have an effective means of ensuring that, during situations such as a condition affecting the network (CAN), network control personnel were aware of the relevant weather monitoring systems that were unserviceable. Who it affects: Network control Issue owner: Queensland Rail Operation affected: Rail: Operations control	Date, status, type Date: 30 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-021-SI-01 Sydney Trains’ Control of worksite access and egress Number: RO-2018-021-SI-01 Description: RO-2018-021-SI-01 :Sydney Trains' control of the access and egress to the project worksite did not ensure that all workers entering the worksite were identified and received an induction. Who it affects: All rail infrastructure managers Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 30 Jun 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2017-066-SI-02Inspection period for blade cracking Number: AO-2017-066-SI-02 Description: AO-2017-066-SI-02:The scheduled inspections recommended by Rolls-Royce to detect cracking in Trent 700 fan blades, were insufficient to detect early onset fatigue cracks in the membrane to panel bond before those cracks could progress to failure. Who it affects: Air transport operators whose aircraft are fitted with Trent 700 engines. Issue owner: Rolls-Royce plc Operation affected: Aviation: Air transport	Date, status, type Date: 30 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2017-066-SI-01Fatigue cracking of Trent 700 fan blades Number: AO-2017-066-SI-01 Description: AO-2017-066-SI-01:The Trent 700 blade manufacturing process produced a variation in internal membrane-to-panel acute corner geometry that, in combination with the inherent high level of blade panel stress, could lead to increased localised stresses in those corner areas and the initiation and propagation of fatigue cracking. Who it affects: Air transport operators whose aircraft are fitted with Trent 700 engines. Issue owner: Rolls-Royce plc Operation affected: Aviation: Air transport	Date, status, type Date: 30 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2019-014-SI-03Guidance on vehicle-assisted deflation risks Number: AO-2019-014-SI-03 Description: AO-2019-014-SI-03:The Civil Aviation Safety Authority provided no guidance for operators concerning the risks associated with vehicle‑assisted deflation. Who it affects: Commercial Balloon operators that use a vehicle to assist during deflation Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Other	Date, status, type Date: 29 Jun 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2019-014-SI-01Risk management processes Number: AO-2019-014-SI-01 Description: AO-2019-014-SI-01:Picture This Ballooning's safety risk management processes and practices were not sufficient to facilitate the identification of key operational risks associated with vehicle-assisted deflation. Who it affects: Commercial Balloon operators that use a vehicle to assist during deflation Issue owner: Picture This Ballooning Operation affected: Aviation: Other	Date, status, type Date: 29 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2019-014-SI-02Vehicle-assisted deflation procedures Number: AO-2019-014-SI-02 Description: AO-2019-014-SI-02:Picture This Ballooning did not have any procedures for conducting vehicle-assisted deflation. Who it affects: Commercial Balloon operators that use a vehicle to assist during deflation Issue owner: Picture This Ballooning Operation affected: Aviation: Other	Date, status, type Date: 29 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-020-SI-01No procedure to cross-check master circuit diagram Number: RO-2018-020-SI-01 Description: RO-2018-020-SI-01:Queensland Rail did not have a procedure in place to cross-check a master circuit diagram with the existing configuration of the in-field equipment before using the diagram for safety critical work. This removed an opportunity to detect any error in master circuit diagrams. Who it affects: Rail metropolitan passenger Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 05 Jun 2020 Status: Adequately addressed Type: Proactive action
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