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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: RO-2016-006-SI-04Use of all available and reasonably practicable risk controls when parking trams
Number: RO-2016-006-SI-04
Description: RO-2016-006-SI-04:STM did not require the application of all available and reasonably practicable risk controls when parking trams with respect to their location and handbrake application.
Who it affects: Rolling Stock Operators
Issue owner: Sydney Tramway Museum
Operation affected: Rail: Operations control
Date, status, type
Date: 17 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-006-SI-03Attending parked trams
Number: RO-2016-006-SI-03
Description: RO-2016-006-SI-03:STM did not comply with its risk control in ensuring that trams were attended when parked.
Who it affects: Sydney Tramway Museum
Issue owner: Sydney Tramway Museum
Operation affected: Rail: Operations control
Date, status, type
Date: 17 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-006-SI-02 Change management process implementation for safety critical changes
Number: RO-2016-006-SI-02
Description: RO-2016-006-SI-02 :STM did not follow its change management process for adopting the new hardwood chock type. Subsequently, the hardwood chock could not be applied reliably under the ‘J’ class wheel and could not restrict its movement.
Who it affects: Rolling Stock Operators
Issue owner: Sydney Tramway Museum
Operation affected: Rail: Operations control
Date, status, type
Date: 17 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-166-SI-04En route supplement guidance to flight crews
Number: AO-2016-166-SI-04
Description: AO-2016-166-SI-04:The En Route Supplement Australia (ERSA) did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.
Who it affects: Pilots operating into Darwin airport
Issue owner: Darwin International Airport
Operation affected: Aviation: Airports
Date, status, type
Date: 15 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-166-SI-03Operator guidance to flight crews
Number: AO-2016-166-SI-03
Description: AO-2016-166-SI-03:Virgin Australia did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.
Who it affects: Virgin Australia Airlines flight crews operating into Darwin airport
Issue owner: Virgin Australia Airlines
Operation affected: Aviation: Air transport
Date, status, type
Date: 15 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-166-SI-02Limited visual cues for approach at Darwin runway 11/29
Number: AO-2016-166-SI-02
Description: AO-2016-166-SI-02:The absence of centreline lighting and the 60-m width of runway 11/29 at Darwin result in very limited visual cues for maintaining runway alignment during night landings in reduced visibility.
Who it affects: Pilots operating into Darwin airport
Issue owner: Darwin International Airport
Operation affected: Aviation: Airports
Date, status, type
Date: 15 May 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2016-166-SI-01Standards for installation of runway centreline lighting on wider runways
Number: AO-2016-166-SI-01
Description: AO-2016-166-SI-01:Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions. The installation of centreline lighting on wider category I runways is recommended but not mandated by the International Civil Aviation Organization Annex 14.
Who it affects: Operators using runways wider than 50 m without centreline lighting
Issue owner: International Civil Aviation Organization
Operation affected: Aviation: Airports
Date, status, type
Date: 15 May 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2015-107-SI-02NAV ADR DISAGREE procedure
Number: AO-2015-107-SI-02
Description: AO-2015-107-SI-02:A NAV ADR DISAGREE alert can be triggered by either an airspeed discrepancy, or angle of attack discrepancy. The alert does not indicate which, and the associated procedure may lead flight crews to incorrectly diagnosing the source of the alert when the airspeed is erroneous for a short period and ...
Who it affects: Operators of Airbus A320 aircraft
Issue owner: Airbus
Operation affected: Aviation: Air transport
Date, status, type
Date: 04 Apr 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-107-SI-01Priority of NAV ADR DISAGREE alert
Number: AO-2015-107-SI-01
Description: AO-2015-107-SI-01:Although the NAV ADR DISAGREE had more immediate safety implications relating to unreliable airspeed, the ECAM alert priority logic placed this alert below the engine-related faults. As a result, the NAV ADR DISAGREE alert was not immediately visible to the flight crew due to the limited space available on the ...
Who it affects: Operators of Airbus A320 aircraft
Issue owner: Airbus
Operation affected: Aviation: Air transport
Date, status, type
Date: 04 Apr 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2017-044-SI-02Re-evaluating hold speeds for a change in altitude
Number: AO-2017-044-SI-02
Description: AO-2017-044-SI-02:The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude (specifically above flight level 200).
Who it affects: Qantas Airways Boeing 747 flight crew
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2017-044-SI-01Stall prevention and recovery at high altitudes
Number: AO-2017-044-SI-01
Description: AO-2017-044-SI-01:The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle.
Who it affects: Qantas Airways Boeing 747 flight crew
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-001-SI-03Maintenance response to recurring track defects in areas with a degraded formation
Number: RO-2016-001-SI-03
Description: RO-2016-001-SI-03:A more stringent maintenance response than that for an isolated track geometry defect was not considered or implemented in accordance with ARTC’s COP. A more stringent maintenance response should have been considered given the degraded formation and the track’s rapid deterioration between 12-14 January 2016, two days prior to the ...
Who it affects: Rail Infrastructure Managers (RIMs)
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Infrastructure
Date, status, type
Date: 25 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-001-SI-01Shear key installation
Number: RO-2016-001-SI-01
Description: RO-2016-001-SI-01:The shear key was not installed in accordance with the geotechnical engineer’s specification with respect to the following: a) It did not include a cross-drain. b) Its width was less than the specified width.
Who it affects: Rail Infrastructure Managers (RIMs)
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Infrastructure
Date, status, type
Date: 25 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-001-SI-02Surface drainage in areas with degraded formations
Number: RO-2016-001-SI-02
Description: RO-2016-001-SI-02:The location did not have adequate surface drainage which likely contributed to formation degradation over time.
Who it affects: Rail Infrastructure Managers (RIMs)
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Infrastructure
Date, status, type
Date: 25 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2017-016-SI-01Track defect management
Number: RO-2017-016-SI-01
Description: RO-2017-016-SI-01:ARTC allowed identified track twist defects to remain in track contrary to network track geometry requirements.
Who it affects: Track Managers
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Freight
Date, status, type
Date: 06 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2018-002-SI-01Train driver maintenance of competency assurance
Number: RO-2018-002-SI-01
Description: RO-2018-002-SI-01:Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements.
Who it affects: Queensland Rail Citytrain rail traffic drivers
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Feb 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2017-001-SI-01Inadequate on-board documentation
Number: MO-2017-001-SI-01
Description: MO-2017-001-SI-01:Guidelines for the provision, care and use of shipboard equipment were not supported by suitable documentation. The only documentation was for mobile scaffolding equipment of different design and not for that in use on the ship.
Who it affects: All owners and operators and crewmembers involved in working aloft
Issue owner: Asia Maritime Pacific
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 21 Feb 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-007-SI-04Audit response
Number: MO-2015-007-SI-04
Description: MO-2015-007-SI-04:The regional harbour master and the pilotage service did not have processes in place to follow up audit findings, to ensure that they were appropriately monitored, actioned and closed out in a timely manner.
Who it affects: All ships entering and departing Townsville under pilotage
Issue owner: Maritime Safety Queensland
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 Feb 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-007-SI-03Tug reduction process
Number: MO-2015-007-SI-03
Description: MO-2015-007-SI-03:The Port Procedures manual for Townsville allowed shipping agents to request a tug reduction without the knowledge of the ship’s master.
Who it affects: All ships entering and departing Townsville under pilotage
Issue owner: Maritime Safety Queensland and Port of Townsville Limited Pilotage Services
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 Feb 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-007-SI-02Contingency planning
Number: MO-2015-007-SI-02
Description: MO-2015-007-SI-02:The Port of Townsville Limited Pilotage Services’ Pilotage Service Safety Management System did not have documented guidance on berthing manoeuvres nor any associated contingencies.
Who it affects: All ships entering and departing Townsville under pilotage
Issue owner: Port of Townsville Limited Pilotage Services
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 Feb 2019
Status: Adequately addressed
Type: Proactive Action
First page Page 2 of 87 Last page Total records: 1740