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Recommendation issued to: TransAdelaide

Recommendation details
Output No: RR20070032
Date issued: 20 December 2007
Safety action status:
Background: Why this Recommendation was developed

Output text

Safety Issue

TransAdelaide's SPAD investigation process was unlikely to have provided a clear understanding of factors that may have contributed to past SPADs or a sound basis for identification of safety actions to prevent similar occurrences. A recommended action in TransAdelaide's SPAD risk management plan was the establishment of a SPAD investigation group to investigate individual SPADs, compile data, conduct analysis, determine trends, make recommendations, report and oversee implementation. It was not evident that this recommendation had been fully implemented at the time of the incident.

Safety Recommendation

The Australian Transport Safety Bureau recommends that TransAdelaide undertake further work to address this safety issue.

 
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Last update 05 April 2012