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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: RO-2015-015 SI-02Low rim thickness
Number: RO-2015-015 SI-02
Description: RO-2015-015 SI-02:Despite a number of incidents, Pacific National did not take adequate action, before the derailment, to reduce the risk of wheel defects, especially in light of previously identified contributors such as low rim thickness. 
Who it affects: All owners and operators of heavy haul freight wagons.
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 30 Jun 2016
Status:
Issue, description, who it affects
Issue: RO-2015-015 SI-01Wheel inspection processes
Number: RO-2015-015 SI-01
Description: RO-2015-015 SI-01:The wheel inspection processes and systems were not effective in detecting surface damage or cracks on the R4 wheel on wagon NHIH97081 prior to the wheel failure.
Who it affects: All owners and operators of heavy haul freight wagons
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 30 Jun 2016
Status:
Issue, description, who it affects
Issue: AO-2014-032-SI-01Inadvertent activation of the elevator control system - pitch uncoupling mechanism
Number: AO-2014-032-SI-01
Description: AO-2014-032-SI-01:Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 15 Jun 2016
Status:
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-100-SI-02Alerting function of special weather reports (SPECI) is not met by the automatic broadcast services
Number: AO-2013-100-SI-02
Description: AO-2013-100-SI-02:The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.
Who it affects: All pilots operating into non-major airports accessing an automatic broadcast service
Issue owner: Airservices Australia in consultation with the Bureau of Meteorology
Operation affected: Aviation: Air transport
Date, status, type
Date: 31 May 2016
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2013-100-SI-01Limited provision of flight information service for some non major airports
Number: AO-2013-100-SI-01
Description: AO-2013-100-SI-01:For many non‑major airports in Australia, flight crews of arriving aircraft can access current weather information using an Automatic Weather Information Service via very high frequency radio, which has range limitations. Where this service is available, air traffic services will generally not alert pilots to significant deteriorations in current weather ...
Who it affects: All pilots operating into non-major airports accessing an Automatic Weather Information Service
Issue owner: Airservices Australia in consultation with the Bureau of Meteorology
Operation affected: Aviation: Air transport
Date, status, type
Date: 31 May 2016
Status:
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-074-SI-02Compromised separation recovery training
Number: AO-2014-074-SI-02
Description: AO-2014-074-SI-02:Airservices Australia had not provided en route air traffic controllers with effective simulator-based refresher training in identifying and responding to compromised separation scenarios, at intervals appropriate to ensure that controllers maintained effective practical skills.
Who it affects: All Airservices Australia en route air traffic controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 13 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-074-SI-01Air traffic control shift management practices
Number: AO-2014-074-SI-01
Description: AO-2014-074-SI-01:The utilisation of  shift sharing practices for the Tops controllers resulted in them sustaining a higher workload over extended periods without a break, during a time of day known to reduce performance capability.
Who it affects: All Airservices Australia air traffic controllers operating on night shifts
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 13 May 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-212-SI-01Identification of pitot probe in the trouble shooting manual
Number: AO-2013-212-SI-01
Description: AO-2013-212-SI-01:The relevant tasks in the trouble shooting manual did not specifically identify the pitot probe as a potential source of airspeed indication failure.
Who it affects: Maintenance engineers
Issue owner: Airbus
Operation affected: Aviation: Air transport
Date, status, type
Date: 06 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-009-SI-04Forecast terminology
Number: MO-2014-009-SI-04
Description: MO-2014-009-SI-04:Fremantle Ports’ staff did not understand the significance of some wind and weather terminology used in the BoM forecast. Consequently, port procedures triggered by a BoM ‘gale’ or ‘severe weather’ warning such as preparing the tugs and calling the harbour master were not followed.
Who it affects: Port and ship operators
Issue owner: Fremantle Port Authority (Fremantle Ports)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-009-SI-03Weather event management
Number: MO-2014-009-SI-03
Description: MO-2014-009-SI-03:Fremantle Ports’ procedures for adverse weather were not adequate for weather that could reasonably be expected to occur. Some procedures could not be reasonably implemented and other were not monitored for compliance.
Who it affects: All ships berthed in Fremantle’s Inner Harbour
Issue owner: Fremantle Port Authority (Fremantle Ports)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-009-SI-02Bureau of Meteorology weather warnings
Number: MO-2014-009-SI-02
Description: MO-2014-009-SI-02:The Bureau of Meteorology (BoM) marine forecast title of ‘strong wind warning’ understated the ‘damaging winds’ expected during the ‘severe thunderstorm’. The forecast did not use recognised marine weather terms for wind speed, such as ‘gale force’.
Who it affects: Port, boat and ship operators in Australian coastal waters
Issue owner: Bureau of Meteorology (BoM)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-009-SI-01Fremantle Ports’ risk assessment
Number: MO-2014-009-SI-01
Description: MO-2014-009-SI-01:Fremantle Ports’ assessment of risks associated with a ship contacting the Fremantle Rail Bridge as a result of a breakaway, particularly from berths 11 and 12, was limited. Preventing a breakaway from berths where the wind was likely to be on a ship’s beam had not been considered. Similarly, the ...
Who it affects: All users of Fremantle’s Inner Harbour, including the Fremantle Rail Bridge
Issue owner: Fremantle Port Authority (Fremantle Ports)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-005-SI-04Train / platform clearances
Number: RO-2014-005-SI-04
Description: RO-2014-005-SI-04:Due to the curvature of the track, a wide gap existed between the platform and train at the Heyington Railway Station. There are several stations on the Melbourne metropolitan rail network where wide gaps exist between platforms and trains due to track curvature. These gaps pose a risk to passengers.
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-005-SI-03Standards for train / platform clearances
Number: RO-2014-005-SI-03
Description: RO-2014-005-SI-03:The existing standards stipulated minimum clearances between trains and platforms but did not consider the effect of the resulting gaps with respect to safe accessibility. 
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-005-SI-02Inadequacy of the doors open warning device
Number: RO-2014-005-SI-02
Description: RO-2014-005-SI-02:The train door open/close indicator on the driver’s control console was inadequate as a warning device once the traction interlock had deactivated. 
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: No longer relevant
Type: Recommendation
Issue, description, who it affects
Issue: RO-2014-005-SI-01The train could be moved with the carriage doors open
Number: RO-2014-005-SI-01
Description: RO-2014-005-SI-01:As designed, the traction interlock automatically deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-09Ship firefighting cache
Number: MO-2014-008-SI-09
Description: MO-2014-008-SI-09:The large size and weight of the ship firefighting cache made it difficult for the duty Port Hedland volunteer firefighter to transport it to the wharf. 
Who it affects: All agencies charged with shipboard firefighting
Issue owner: Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-08Professional firefighters in Port Hedland
Number: MO-2014-008-SI-08
Description: MO-2014-008-SI-08:The limited professional firefighting capability in Port Hedland restricted the ability to launch an effective response to the fire on board Marigold.   
Who it affects: All agencies charged with shipboard firefighting
Issue owner: Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-07Access control
Number: MO-2014-008-SI-07
Description: MO-2014-008-SI-07:Suitable atmospheric testing equipment was not available in Port Hedland to ensure safe entry to fire-affected spaces on board Marigold. Access to these areas was not controlled until 53 hours after the fire.  
Who it affects: All agencies charged with shipboard firefighting in regional ports
Issue owner: DFES
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Not addressed
Issue, description, who it affects
Issue: MO-2014-008-SI-06Incident control
Number: MO-2014-008-SI-06
Description: MO-2014-008-SI-06:The emergency response plans for a ship fire in Port Hedland did not clearly define transfer of control procedures for successive incident controllers from different organisations or contain standard checklists for their use. 
Who it affects: All agencies charged with shipboard firefighting
Issue owner: BHP Billiton, Pilbara Ports Authority and Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Recommendation
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