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Recommendations and Safety Advisory Notices

Recommendations and Safety Advisory Notices

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Central to ATSB's investigation of aviation accidents and incidents is the early identification of safety deficiencies in the civil aviation environment. While the Bureau issues recommendations to regulatory authorities, operators, manufacturers or other agencies in order to address safety deficiencies, its preference is for industry organisations to make safety enhancements during the course of an investigation. The Bureau is pleased to report positive safety action in its final reports instead of needing to make formal recommendations. Recommendations may be issued in conjunction with ATSB reports or independently. A safety deficiency may lead to a number of similar recommendations, each issued to a different agency.

The ATSB does not have the resources to carry out a full cost-benefit analysis of every recommendation. The cost of any recommendation must always be balanced against its benefits to safety, and aviation safety involves the whole community. Such analysis is a matter for the body to which the recommendation is addressed (for example the Civil Aviation Safety Authority in consultation with the industry).

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<< < > >>Page 1 of 79 - Total Records: 783
Reference
Number
Issue
Date
RecommendationOrganisation
RR2008002930-Jun-2008The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes safety action to address this safety issue.

Safety Issue

It is unlikely that the combined effects of the track geometry defects were considered when assessing a track speed suitable for safe rail operations, especially considering that the horizontal alignment defect was below the documented defect limits and associated response codes.

RR2008003030-Jun-2008The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes safety action to address this safety issue.

Safety Issue

It is unlikely that the dynamics of poorer riding rolling stock were considered when assessing the track geometry defect and determining a suitable speed limit for train operations.

RR2008002627-Jun-2008The Australian Transport Safety Bureau recommends that the Department for Transport, Energy and Infrastructure (Level Crossing Unit) take action to address this safety issue.

Safety Issue

During the investigation it was noted that the Moloney Road level crossing had a history of collisions and near misses. A mechanism should be considered to flag for attention, level crossings that have not been identified as posing a high risk when assessed using the ALCAM but have a history of incidents and/or accidents.

RR2008002727-Jun-2008The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation take action to address this safety issue.

Safety Issue

During the investigation it was noted that the Australian Rail Track Corporation and the City of Playford Council did not have an 'Interface Agreement' covering their responsibilities with respect to the maintenance of level crossing signage. Maintenance responsibilities need to be clearly defined.

RR2008002827-Jun-2008The Australian Transport Safety Bureau recommends that Pacific National take action to address this safety issue.

Safety Issue

The sounding of the locomotive horn was not at the whistle board as prescribed, however there was time for the truck driver to take defensive action had he heard it.

MR2008002226-Jun-2008

Baltimar Boreas's safety management system provided no guidance for the maintenance or replacement of the generator flexible fuel hoses.

The Australian Transport Safety Bureau recommends that Baltimar A/S take action to address this safety issue.

MS2008001926-Jun-2008

The fumigation contractor did not adequately consider the risks associated with burying the aluminium phosphide fumigant in the cargo.

The Australian Transport Safety Bureau advises that ship owners, operators, masters and fumigation contractors should consider the safety implications of this safety issue and to take action where it is considered appropriate.

MS2008002026-Jun-2008

Jin Hui's master was not supplied with sufficient information to enable the ship’s crew to effectively supervise the application of the aluminium phosphide fumigant.

The Australian Transport Safety Bureau advises that ship owners, operators, masters and fumigation contractors should consider the safety implications of this safety issue and to take action where it is considered appropriate.

MS2008002125-Jun-2008

The maintenance of the generator flexible fuel hoses was inadequate. Inappropriate temporary repairs had been made and hoses longer than specified by the generator manufacturer had been used in the past. As a result, some hoses were in poor condition due to wear and this had not been noted during previous surveys, audits and inspections.

The Australian Transport Safety Bureau advises that ship owners, operators and managers should consider the safety implications of this safety issue and take action when considered appropriate.

MS2008002225-Jun-2008

The generator manufacturer's instruction book provided no guidance for the maintenance or routine replacement of the flexible fuel hoses.

The Australian Transport Safety Bureau advises that the manufacturers of marine diesel engines should consider the safety implications of this safety issue and take action when considered appropriate.

<< < > >>Page 1 of 79 - Total Records: 783
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Last Updated: 24 November, 2006