Recommendations and Safety Advisory Notices

The Australian Transport Safety Bureau recommends that WestNet Rail takes action to address this safety issue.

Safety Issue

There was no record to indicate that a worn section of rail, inserted into the track on 25 July 2007, was tested as being suitable for reuse as prescribed in the WestNet Rail Standard Gauge Mainline Code of Practrice. The lack of construction and maintenance documentation compromises the ability to maintain railway infrastructure safely and places greater importance on adhering to mandated test procedures.

Action taken by WestNet Rail

WestNet Rail has advised:

A complete review of WestNet Rail’s ultrasonic testing regime is being conducted by Monash University's Institute of Railway Technology to ensure best practice is being followed. WestNet Rail has also advised that it is establishing an electronic track asset management system.

ATSB assessment of action

The Australian Transport Safety Bureau notes that WestNet Rail has taken action in response to this safety issue. These actions are still in the formative stage. WestNet Rail does not yet have systems in place that address the specific safety issue.

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

Safety Issue

There was no clear guidance within the WestNet Rail rules for train crews that defined an allowable speed associated with proceeding 'cautiously'. Had the train been travelling at a slower speed it is probable that the extent of damage caused by the derailment would have been less.

Action taken by WestNet Rail RO-2007-006-NSA-007

WestNet Rail has advised:

Immediately after the derailment WestNet Rail implemented, on the 47 kg/m track equipped with CTC, between Koolyanobbing and West Kalgoorlie, the following instruction – Upon any unexplained illumination of a track or block section in the above section the Train controller must not permit any train to enter the section concerned until the Infrastructure person and the Safeworking Technician on call have both been advised and attended to ascertain the cause and corrective action implemented. The above instruction applies 24 hours a day until further notice.

ATSB assessment of action

The Australian Transport Safety Bureau notes that WestNet Rail has taken action in response to this safety issue. However, WestNet Rail has not addressed the lack of guidance within their rules for train crews who are requested to proceed 'cautiously'. WestNet Rail’s rules in this regard are not best practice when compared to rules in other rail systems.

The ATSB recommends that CASA address this safety issue.

Safety issue

CASA did not seek information to establish whether conditions '...necessary for the safety of other airspace users and persons on the ground or water' were required prior to issuing the Special Certificate of Airworthiness.

Action taken by CASA

In its response to this safety issue, CASA provided the following reponse to the ATSB on 1 June 2009:

I refer to your email dated 15 May 2009 regarding a further draft of Transport Safety Report AO-2007-066. I understand CASA has already provided comments on the safety management issue for the pilot. However, the current draft of the report appears to have broadened this issue to include other persons ie "CASA did not seek information to establish whether conditions '...necessary for the safety of other airspace users and persons on the ground or wate'" were required prior to issuing the Special Certificate of Airworthiness.

In CASA's view the new safety issue is irrelevant to the accident because no other airspace users and persons on the ground and water were affected. The person who was fatally injured was the pilot, a participant and fully aware of the risk. CASA did not seek information'...necessary for the safety of other airspace users and persons on the ground or water' were required prior to issuing the Special Certificate of Airworthiness, because it based the safety determination on the information submitted by the applicant initially as part of the application and subsequent flight test plan. This information and the conditions set out on the Special Certificate of Airworthiness and other required operational approvals (low level flight over water) are intended to ensure the safety of other airspace users and persons on the ground or water.

In those cases where such inquiries are or might be relevant, CASA will not hesitate to make them and formulate and impose such additional conditions (if any) as may be necessary in the interest of safety, on that basis.

ATSB assessment of response

The potential for risk to other parties in relation to the experimental flight test was identified by CASA in its advice to the engineer of 29 November. If there had been due consideration of that potential risk in the operator's application for a Special Certificate of Airworthiness and ‘subsequent flight test plan’, then the additional advice to the engineer, which was provided after the issue of the certificate, would not have been warranted. When considering the issue of future Special Certificates of Airworthiness in the experimental category, CASA needs to be able to assure itself that adequate information is gathered to enable an informed decision on the conditions '...necessary for the safety of other airspace users and persons on the ground or water'.

The ATSB recommends that CASA address this safety issue.

Safety issue

CASA did not seek information to establish whether conditions '...necessary for the safety of other airspace users and persons on the ground or water' were required prior to issuing the Special Certificate of Airworthiness.

Action taken by CASA

In its response to this safety issue, CASA provided the following reponse to the ATSB on 1 June 2009:

I refer to your email dated 15 May 2009 regarding a further draft of Transport Safety Report AO-2007-066. I understand CASA has already provided comments on the safety management issue for the pilot. However, the current draft of the report appears to have broadened this issue to include other persons ie "CASA did not seek information to establish whether conditions '...necessary for the safety of other airspace users and persons on the ground or water'" were required prior to issuing the Special Certificate of Airworthiness.

In CASA's view the new safety issue is irrelevant to the accident because no other airspace users and persons on the ground and water were affected. The person who was fatally injured was the pilot, a participant and fully aware of the risk. CASA did not seek information '...necessary for the safety of other airspace users and persons on the ground or water' were required prior to issuing the Special Certificate of Airworthiness, because it based the safety determination on the information submitted by the applicant initially as part of the application and subsequent flight test plan. This information and the conditions set out on the Special Certificate of Airworthiness and other required operational approvals (low level flight over water) are intended to ensure the safety of other airspace users and persons on the ground or water.

In those cases where such inquiries are or might be relevant, CASA will not hesitate to make them and formulate and impose such additional conditions (if any) as may be necessary in the interest of safety, on that basis.

ATSB assessment of response

The potential for risk to other parties in relation to the experimental flight test was identified by CASA in its advice to the engineer of 29 November. If there had been due consideration of that potential risk in the operator's application for a Special Certificate of Airworthiness and ‘subsequent flight test plan’, then the additional advice to the engineer, which was provided after the issue of the certificate, would not have been warranted. When considering the issue of future Special Certificates of Airworthiness in the experimental category, CASA needs to be able to assure itself that adequate information is gathered to enable an informed decision on the conditions '...necessary for the safety of other airspace users and persons on the ground or water'.

Safety Issue

A single extra pulse echo was recorded during the last ultrasonic inspection of the rail, nine months before the derailment, in the vicinity of the failure. An examination with handheld ultrasonic testing equipment at the time concluded there was no sizable defect in the rail, even though the evidence suggests that the fatigue cracks existed (to some degree) at the time.

The Australian Transport Safety Bureau recommends that the ARTC take further action to address this safety issue.

Safety Issue

Unused bolt-holes in the rail web are sufficient stress concentrators to result in the initiation and propagation of fatigue cracking, ultimately leading to the failure of the rail.

Action taken by the ARTC

The ARTC has introduced a common standard for bolt-hole crack limits across the whole ARTC network. The standard has lower thresholds for intervention.

ATSB assessment of response/action

Although the ARTC has addressed the risk of crack propagation in unused rail bolt-holes, the risk of crack initiation still exists under cyclic loading typical of actual rail traffic.

Safety Issue

Northern Fortune's third mate did not contact Allena or take any steps to determine if a collision had occurred and did not inform the ship's master of the incident. Therefore, he disregarded his legal and moral obligations to ensure the safety of the fishing vessel's crew. It is a requirement for flag States to ensure that their ships' masters effectively implement the United Nations Convention of the Laws of the Sea (UNCLOS) requirements to stop and render assistance to those who are in danger of being lost at sea.

Safety issue

It was not a requirement for Allena to be fitted with either a radar reflector or an Automatic Identification System (AIS) unit. Consequently, the vessel was probably difficult to detect electronically in the prevailing weather conditions.

Safety issue

The Queensland regulations for fishing vessel certificates of competency are ambiguous and are not consistent with the Uniform Shipping Laws Code (USL Code) or the National Standard for Commercial Vessels (NSCV). The regulations allow a fishing vessel to be operated up to 200 miles from the coast by a skipper who may not have been appropriately trained, experienced or qualified for that operational area.

The Australian Transport Safety Bureau recommends that Atlantic Bulk Carriers Management takes safety action to address this safety issue.

Safety Issue

Atlantic Eagle's safety management system procedures for navigation, aimed at ensuring the ship’s safe progress and safeguarding against single person errors, had not been effectively implemented on board the ship and were not followed on 15 July 2008.