Formal safety issues and actions

This section reports on the formal safety issues and actions issued by the ATSB in 2015–16 and their current status.

ATSB investigations primarily improve transport safety by identifying and addressing safety issues. Safety issues are events or conditions that increase safety risk and:

Safety issues will usually refer to an organisation's risk controls, or to a variety of internal and external organisational influences that impact the effectiveness of its risk controls. They are factors for which an organisation has some level of control and responsibility and, if not addressed, will increase the risk of future accidents.

The ATSB prefers to encourage stakeholders to take proactive safety action to address safety issues identified in its reports. Nevertheless, the ATSB may use its powers under the TSI Act to make a formal safety recommendation either during or at the end of an investigation—depending on the level of risk associated with a safety issue and the extent of corrective action already taken.

When safety recommendations are issued, they clearly describe the safety issue of concern—they do not provide instructions or opinions on a preferred corrective action. Like equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the organisation to which an ATSB recommendation is directed to assess the costs and benefits of any means of addressing a safety issue and act appropriately.

When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation and details of any proposed safety action to give effect to the recommendation.

The ATSB can also issue a Safety Advisory Notice (SAN) suggesting that an organisation, or an industry sector, consider a safety issue and take appropriate action. There is no requirement for a formal response to a SAN.

Safety issues are broadly classified in terms of their level of risk:

All ATSB safety issues and associated safety actions, along with the most recent status, are published on the ATSB website for all investigation reports released since July 2010.

Safety issues identified through ATSB investigations

All safety issues are risk assessed by the ATSB. In 2015–16, the ATSB identified the following number of safety issues.

Table 5: Number of safety issues identified in 2015–16

Safety issue risk

Aviation

Marine

Rail

Total

Critical

0

0

0

0

Other

32

23

30

85

Total

32

23

30

85

Safety action is sought to address any safety issues when proactive safety action is not forthcoming. Once safety action has been undertaken, the ATSB conducts another risk assessment of the safety issue. When the post-action risk assessment results in either an acceptable level of risk or a risk as low as reasonably practicable, the safety issue status is categorised as 'adequately addressed'.

The Portfolio Budget Statements (PBS) specify, as two of the ATSB's key performance indicators (KPIs), that:

KPI status of safety issues identified in 2015–16 website Links

There were no critical risk safety issues identified through ATSB investigations in 2015–16.

The breakdown of other safety issues, by transport mode, is summarised in the following table:

Table 6: Status of safety issues identified in 2015–16

STATUS OF SAFETY ISSUES

AVIATION

MARINE

RAIL

PER CENT

Adequately addressed

24

15

19

68%

Partially addressed

0

3

0

4%

Not addressed

0

0

0

0%

No longer relevant

0

0

1

1%

Safety action still pending

8

5

10

27%

Total

32

23

30

100%

Reponses to safety issues identified in 2015–16 website Links

The tables below document each safety issue identified in 2015–16 and its current status assigned by the ATSB, along with the justification for that status.

Table 7: Aviation—Responses to safety issues identified in 2015–16

SAFETY ISSUE

STATUS

STATUS JUSTIFICATION

AO-2012-120 Operational non-compliance involving Boeing 747, N409MC, 11 km ESE Melbourne Airport, Victoria, 9 September 2012

AO-2012-120-SI-01: Unlike other Australian standard arrival routes that included a visual segment, the visual approach to runway 34 at Melbourne via the SHEED waypoint could be issued to super or heavy jet aircraft operated by foreign operators, despite there being more safety occurrences involving the SHEED waypoint than other comparable approaches.

Adequately addressed

The ATSB is satisfied that the action taken by Airservices Australia to issue a local instruction and the amendment of the Manual of Air Traffic Services in March 2016 has eliminated the risk associated with the safety issue.

AO-2012-120-SI-02: The LIZZI FIVE RWY 34 VICTOR ARRIVAL required a 3.5° descent profile after passing the SHEED waypoint for visual approach to runway 34 at Melbourne, increasing the risk of an unstable approach.

Adequately addressed

The ATSB is satisfied that the action taken by the Civil Aviation Safety Authority in reviewing the approach design, in conjunction with the amendment of the Manual of Air Traffic Services in March 2016 (AO-2012-120-NSA-050) has eliminated the risk associated with the safety issue.

AO-2013-047 Flight path management and ground proximity warning involving Airbus A330-202 VH-EBV 15 km NNE of Melbourne Airport, Victoria, 8 March 2013

AO-2013-047-SI-01: Qantas provided limited guidance on the conduct of a visual approach and the associated briefing required to enable the flight crew to have a shared understanding of the
intended approach.

Adequately addressed

The ATSB is satisfied that the safety action by Qantas to enhance guidance on the conduct of visual approaches adequately addresses this safety issue.

AO-2013-095 Flight path management occurrence involving Boeing 737, VH-YIR, Sydney Airport, New South Wales, 4 June 2013

AO-2013-095-SI-01: The Virgin Australia procedures did not require its flight crew to, whenever practicable, announce flight mode changes.

Adequately addressed

The ATSB is satisfied that the change in policy requiring the announcement of flight mode changes has adequately addressed the safety issue.

AO-2013-095-SI-02: Air traffic control did not, and was not required to, provide traffic information to aircraft using adjacent runways and abeam each other during independent visual approach procedures at Sydney.

Adequately addressed

The ATSB is satisfied that the safety action implemented by Airservices Australia for Sydney air traffic control to provide traffic advice to pilots whenever aircraft operate within 1 NM of traffic on the adjacent final approach during independent visual approach procedures has adequately addressed the safety issue.

AO-2013-100 Landing below minima due to fog involving B737s VH-YIR and VH-VYK, Mildura Airport, Victoria, 18 June 2013

AO-2013-100-SI-02: The automatic broadcast services do not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thereby not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

Safety action still pending

 

AO-2013-130 Descent below approach path involving Boeing 777, VH-VPF Melbourne Airport, Victoria, 15 August 2013

AO-2013-130-SI-01: The presentation of the runway 34 visual approach procedure in the operator's Route and Airport Information Manual increased the risk of the runway threshold crossing altitude being entered into the runway extension waypoint without being detected.

Adequately addressed

The ATSB is satisfied that the safety action by the operator to discontinue the use of the SHEED approach to runway 34 at Melbourne by its Boeing 777 crews minimises the risk associated with the safety issue.

AO-2013-160 Loss of separation involving a Beechcraft B300, VH-FIZ and a formation of four Boeing FA/18 aircraft, near Williamtown, New South Wales, 19 September 2013

AO-2013-160-SI-01: The applicability (for the Department of Defence air traffic services) of a general requirement to conduct aviation risk assessments for complex, new, unusual or irregular activities was open to interpretation.

Adequately addressed

Changes made to the Department of Defence aviation risk management instructions have clarified those activities that require a review of risk assessments.

AO-2013-172 Engine shut down in-flight, Airbus A330-302, B-18358, 887 km ENE of Darwin, Northern Territory, 3 October 2013

AO-2013-172-SI-01: Debris originating from the starter failure was not contained by the starter casing and severed the number one engine Bsump oil scavenge pipe.

Adequately addressed

The action taken with regards to the change in design will eliminate those air turbine starter failures associated with single pawl and ratchet crash engagements, however, it will not completely eliminate failures (contained or otherwise) from all causes. Nevertheless, as a result of these safety actions, the ATSB is satisfied that the likelihood and consequence associated with these starter failures will remain low.

AO-2013-187 In-flight break-up involving modified PZL Mielec M18A Dromader, VH TZJ, 37 km west of Ulladulla, New South Wales, 24 October 2013

AO-2013-187-SI-01: Operators of some Australian M18 Dromaders, particularly those fitted with turbine engines and enlarged hoppers and those operating under Australian supplemental type certificate (STC) SVA521, have probably conducted flights at weights for which airframe life factoring was required but not applied. The result is that some of these aircraft could be close to or have exceeded their prescribed airframe life, increasing the risk of an in-flight failure of the aircraft's structure.

Adequately addressed

The ATSB considers that the Civil Aviation Safety Authority has taken all reasonable steps to alert operators of M18 aircraft of the requirement to correctly calculate and record all flight times that have service life factors applicable to them.

AO-2013-187-SI-02: Although wing removal was necessary to provide adequate access for effective visual and magnetic particle inspections of M18 wing attachment fittings, the aircraft manufacturer's service bulletin E/02.170/2000 allowed the wings to remain attached during these inspections.

Adequately addressed

The improved clarity for operators/maintainers in Service Letter M19/034/2016 should significantly reduce the likelihood, and therefore risk, of an organisation attempting to develop a system whereby the wings are not removed and an inappropriate inspection method used.

AO-2013-187-SI-03: The eddy current inspection used on VH-TZJ, and other M18 aircraft, had not been approved by the Civil Aviation Safety Authority as an alternate means of compliance to airworthiness directive AD/PZL/5. This exposed those aircraft to an inspection method that was potentially ineffective at detecting cracks in the wing attachment fittings.

Adequately addressed

The ATSB is satisfied that the actions taken by the Civil Aviation Safety Authority, involving amendments to airworthiness directive AD/PZL/5, address the safety risk associated with this issue.

AO-2013-187-SI-04: Operation of M18 aircraft with a more severe flight load spectrum results in greater fatigue damage than anticipated by the manufacturer when determining the service life of the M18. If not properly accounted for, the existing service life limit, and particular inspection intervals, may not provide the intended level of safety.

Adequately addressed

At the time of publishing this report, there were 12 registered operators of PZL M18 aircraft on the Australian Civil Register. The ATSB has sent a copy of this report to each of those operators to alert them of this safety issue.

AO-2013-187-SI-06: The documented procedure for eddy current inspection of M18 wing attachment fittings did not assure repeatable, reliable inspections.

Adequately addressed

As a result of the actions taken by the Civil Aviation Safety Authority in response to AO-2013-187-SI-03, the eddy current inspection procedure is explicitly prohibited from use. This action has minimised the safety risk associated with this safety issue.

AO-2013-187-SI-07: Important information relating to Civil Aviation Safety Authority (CASA) airworthiness directive AD/PZL/5 was not contained in CASA's airworthiness directive file, but on other CASA files with no cross-referencing between those files. This impacted CASA's future ability to reliably discover that information and make appropriately informed decisions regarding the airworthiness directive.

Adequately addressed

A search of the ATSB occurrence database identified no occurrences where separate, non-referenced AD files were found to have contributed to the occurrence. The ATSB considers that although some risk remains, it is as low as reasonably practicable.

AO-2013-187-SI-08: The Civil Aviation Safety Authority did not have a defined process for a robust, systematic approach to the assessment and approval of alternative non-destructive inspection procedures to ensure that the proposed method provided an equivalent, or better, level of safety than the original procedure.

Safety action still pending

AO-2013-187-SI-09: The engineering justification package supporting Australian supplemental type certificate SVA521 did not contain consideration of the effect an increase in the average operating speed could have on the rate of fatigue damage accumulation.

Adequately addressed

The cancellation of supplemental type certificate SVA521 will prevent its operational use, thereby addressing the safety issue.

AO-2013-212 Air data system failure involving Airbus A330-243, A6-EYJ near Brisbane Airport Queensland, 21 November 2013

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.

Adequately addressed

The actions taken by Airbus to modify the trouble shooting manual significantly reduce the risk of pitot probe related problems remaining undetected during investigation of airspeed loss or discrepancy events.

AO-2013-226 In-flight break-up involving de Havilland DH 82A Tiger Moth, VH-TSG, 300 m east of South Stradbroke Island, Queensland, 16 December 2013

AO-2013-226-SI-01: The two JRA-776-1 tie rods fitted to VH-TSG had significant pre-existing fatigue cracks in the threaded sections.

Adequately addressed

The safety action by the UK Civil Aviation Authority, which was automatically mandated by the Civil Aviation Safety Authority and the Civil Aviation Authority of New Zealand, minimises the safety risk associated with this safety issue. Since the release of safety issue AO-2013-226-SI-01, the ATSB has, as a result of its investigation, a clearer understanding of the development, manufacture, installation and use of the JRA-776-1 fuselage lateral tie rods. This has resulted in the identification of a number of additional safety issues that present a risk to the operation of all DH82 or DH82A Tiger Moth aircraft fitted with these tie rods. Safety actions taken to address the identified risks follow (see safety issues
AO-2013-226-SI-04, AO-2013-226-SI-05, AO-2013-226-SI-07 and AO-2013-226-SI-02).

AO-2013-226-SI-02: The manufacturer's quality system did not prevent non-conforming tie rods from being released for use on aircraft.

Adequately addressed

As a result of the safety action taken by the United Kingdom Civil Aviation Authority, New Zealand Civil Aviation Authority and the Civil Aviation Safety Authority in response to safety issue AO2013-226-SI-01, all JRA-776-1 tie rods were removed from service. This action minimises the safety risk associated with this safety issue.

AO-2013-226-SI-03: Together with a number of other Australian Tiger Moths, VH-TSG was fitted with non-standard Joint H attachment bolts that did not conform to the original design with the result that the integrity of the Joint H could not be assured.

Safety action still pending

 

AO-2013-226-SI-04: When approving the change in material for the manufacture of the replacement tie rods, the design engineer did not identify that the original parts had a life limitation, or that they had shown susceptibility to fatigue cracking. As a result, the engineer did not compare the fatigue performance of the alternative design to the original, and the replacement tie rods were manufactured to that design and released into service with an unknown fatigue life.

Adequately addressed

As a result of the safety action taken by the United Kingdom Civil Aviation Authority, New Zealand Civil Aviation Authority and the Civil Aviation Safety Authority in response to safety issue AO2013-226-SI-01, all JRA-776-1 tie rods were removed from service. This action minimises the safety risk associated with this safety issue.

AO-2013-226-SI-05: The JRA-776-1 fuselage lateral tie rods that were inspected by the ATSB were not appropriately marked with part and serial numbers, affecting the traceability and service history of the parts in a number of aircraft.

Adequately addressed

As a result of the safety action taken by the United Kingdom Civil Aviation Authority, New Zealand Civil Aviation Authority and the Civil Aviation Safety Authority in response to safety issue AO2013-226-SI-01, all JRA-776-1 tie rods were removed from service. This action minimises the safety risk associated with this safety issue.

AO-2013-226-SI-06: It was likely that, because of the Civil Aviation Safety Authority's policy at the time, their engineering assessment of the tie rod design, for inclusion in the manufacturer's Australian Parts Manufacturer Approval, did not consider the service history of the original tie rods or identify that they were subject to airworthiness directive AD/DH 82/10. Consequently, the assessment team was likely unaware that the original tie rods were subject to a life limitation, and did not require the life limits for the replacement tie rods to be established.

Adequately addressed

As a result of the safety action taken by the United Kingdom Civil Aviation Authority, New Zealand Civil Aviation Authority and CASA in response to safety issue AO-2013-226-SI-01, all JRA-776-1 tie rods were removed from service. This action minimises the safety risk associated with this safety issue.

AO-2013-226-SI-07: Over 1,000 parts were approved by the Civil Aviation Safety Authority, for Australian Parts Manufacturer Approval, using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life-limits, were appropriately considered.

Safety action still pending

AO-2013-226-SI-08: Although a number of aerobatic manoeuvres were permitted in Tiger Moth aircraft, there was no limitation on the amount of aerobatic operations that was considered to be safe. As a result, operators may be unaware that a high aerobatic usage may exceed the original design assumptions for the aircraft.

Safety action still pending

 

AO-2014-028 Runway excursion involving a Fairchild Metro 23, VH-UUB at Portland, Victoria, 20 February 2014

AO-2014-028-SI-01: The maintenance program for the aircraft's landing gear did not adequately provide for the detection of corrosion and cracking in the yoke lug bore.

Adequately addressed

Awareness of the issue has been raised by the Civil Aviation Safety Authority and the type certificate holder has improved component maintenance such that the issue should not reoccur without an additional contributing factor.

AO-2014-074 Loss of separation involving Airbus A330, 9V-STQ and Airbus A320, VH-VFH near Tindal, Northern Territory, 24 April 2014

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.

Safety action still pending

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.

Adequately addressed

The ATSB is satisfied that this safety action by Airservices Australia in respect of its compromised separation recovery training satisfactorily addresses the safety issue.

AO-2014-114 Loss of control and collision with terrain involving de Havilland Canada DHC-1 Chipmunk, VHUPD, Coffs Harbour, New South Wales, 29 June 2014

AO-2014-114-SI-01: The spin recovery methods taught by the flying school were inconsistent across instructors and training material, and were not always appropriate for the Chipmunk aircraft type used by the school.

Adequately addressed

The ATSB is satisfied that the actions taken by the flying school to standardise its instructors adequately addresses this safety issue.

AO-2014-16 Data entry error and tailstrike involving a Boeing 737, VH-VZR, Sydney Airport, New South Wales, 1 August 2014

AO-2014-162-SI-01: The Flight Crew Operating Manual procedure for crew comparison of the calculated Vref40 speed, while designed to assist in identifying a data entry error, could be misinterpreted thereby negating the effectiveness of the check.

Adequately addressed

The action by Qantas Airways provides an additional defence to address the risk associated with the safety issue. It does this by directing the crew's attention to the APPROACH REF page in order to verify the Vref40 speed.

AO-2014-163 Collision with terrain involving One Design DR-107 VH-EGT, near Goolwa South Australia, 10 October 2014

AO-2014-163-SI-01: The Civil Aviation Safety Authority did not require builders of amateurbuilt experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. Without a flight manual the builder, other pilots and subsequent owners do not have reference to operational and performance data necessary to safely operate the aircraft.

Safety action still pending

 

AR-2013-107 Engine failures and malfunctions in light aeroplanes: 2009 to 2014

AR-2013-107-SI-01: Thicker 7/16 inch diameter through-bolts, fitted to newer Jabiru engines and some retro-fitted engines, have had limited service to date to confirm early indications that they reduce this risk. Retro-fitting engines with thicker through-bolts has only been recommended for aircraft involved in flight training by JSB031 issue 3. Most light aircraft in service with Jabiru engines continue to use 3/8 inch diameter engine through-bolts which, even after upgrades in accordance with Jabiru service bulletins JSB031 issues 1 and 2, remain at an elevated risk of fracturing within the service life of the bolt, leading to an engine failure or malfunction in flight.

Safety action still pending

 

Table 8: Marine—Responses to safety issues identified in 2015–16 website Links

SAFETY ISSUE

STATUS

STATUS JUSTIFICATION

MO-2014-003 Anchor dragging and contact between ships, Fremantle anchorage, 8 May 2014

MO-2014-003-SI-01: The poor condition of Royal Pescadores' anchoring equipment was indicative of inadequate maintenance. The shipboard management team were not aware of the equipment's maintenance history, nor able to provide relevant documents from the ship's planned maintenance system.

Adequately addressed

The ATSB considers that the proactive safety action taken by the ship's managers will adequately address this safety issue.

MO-2014-003-SI-02: The International Association of Classification Societies (IACS) recommendation for having a means of slipping the anchor cable bitter outside the chain locker had not been provided on board Royal Pescadores. Further, the ship's classification society, ClassNK, does not consider that the IACS recommended slipping arrangement is necessary for reducing safety risk.

Partially addressed

Proactive safety action has been undertaken by Shih Wei Navigation and the ATSB has issued safety advisory notice MO-2014-003-SAN-020.

MO-2014-003-SI-03: While the Fremantle vessel traffic service (VTS) operational procedures were aimed at having precautionary measures in place for adverse weather conditions, the triggers specified in the procedures only referred to Bureau of Meteorology (BoM) issued severe weather and gale warnings. As no wind speed limits were specified, the gale force winds recorded throughout the early hours of 8 May did not trigger the procedural responses until 0600, after the receipt of BoM-issued warnings.

Adequately addressed

The ATSB considers that the proactive safety action taken by Fremantle Port Authority will adequately address this safety issue.

MO-2014-006 Collision between Kota Wajar and the yacht Blazing Keel, Moreton Bay, Queensland, 6 July 2014

MO-2014-006-SI-01: Kota Wajar's safety management system procedures with regard to posting a dedicated lookout were not effectively implemented.

Adequately addressed

Pacific International Lines, Singapore (PIL) has taken adequate proactive safety action. The action includes an enhanced master-pilot exchange checklist and focused audits to monitor and verify compliance with navigational procedures.

MO-2014-006-SI-02: Brisbane Marine Pilots' standard passage plan and master-pilot exchange did not ensure that a ship's bridge team is provided adequate information with respect to local traffic and areas where attention must be paid to other vessels, including small craft.

Adequately addressed

Proactive safety action taken by Brisbane Marine Pilots (BMP). The action taken and proposed by BMP includes amending its standard passage plan, enhancing the master-pilot exchange process and reviewing and amending its pre-arrival information for ship masters.

MO-2014-006-SI-03: Over the past 26 years, investigations into 41 collisions between trading ships and small vessels on the Australian coast have identified that not maintaining a proper lookout and taking early avoiding action, in accordance with the collision regulations, has been a consistent and continuing contributor to such collisions.

Partially addressed

The ATSB has issued a safety advisory notice as a broad safety message to again reiterate the importance of keeping a proper lookout and taking early action to avoid collision between trading ships and small vessels.

MO-2014-008 Engine room fire on board the bulk carrier Marigold, Port Hedland, WA, 13 July 2014

MO-2014-008-SI-01: A number of Marigold's engine room fire doors were held open by wire and/or rope. The open doors allowed smoke to spread across the engine room and into the accommodation spaces.

Adequately addressed

Proactive safety action taken by Korea Leading Company of Ship Management (KLCSM), includes: signage on all fire doors requiring the doors to be closed; company's superintendents will inspect each ship for compliance with this procedure and the condition of each fire door; all crewmembers across the fleet will be trained in fire prevention and response. The safety actions taken should reduce the risk of fire doors been held open.

MO-2014-008-SI-02: The maintenance of the opening/closing arrangements for Marigold's engine room fire dampers, ventilators and other openings was inadequate. A number of these could not be closed, resulting in the inability to seal the engine room to contain and suppress the fire.

Adequately addressed

Proactive safety action taken by KLCSM includes: resources committed to inspect all fire dampers and ventilators on board its ships to identify defects and the condition of each damper/ventilator and any defective equipment will be repaired or replaced; the planned maintenance system amended with enhanced checks for opening and closing mechanisms of ventilators and dampers; focused training on fixed fire extinguishing systems to all crewmembers across its fleet.

MO-2014-008-SI-03: Marigold's Halon gas fixed fire suppression system for the engine room was not fully operational—probably as a result of inadequate maintenance. The multiple failures of the system, at the time of the fire, were not consistent with proper maintenance and testing.

Safety action still pending

Proactive safety action has been undertaken by KLCSM by amended checks and increased frequency for inspecting the main distribution valves. However, the ATSB recommends KLCSM take further action as detailed in the recommendation MO-2014-008-SR-035.

MO-2014-008-SI-04: Marigold's shipboard procedures associated with crew induction, familiarisation, fire drills and safety training were not effectively implemented. As a result, the ship's senior officers were not sufficiently familiar with the Halon system's operation. They did not identify its partial failure and did not activate the override function.

Adequately addressed

Proactive safety action taken by KLCSM includes focused training on fixed fire extinguishing systems to all crewmembers across its fleet.

MO-2014-008-SI-05: Port Hedland's emergency response teams did not use the ship's international shore fire connection. As a result Marigold's fire main was not pressurised with water from ashore.

Safety action still pending

Proactive safety action has been undertaken by BHP Billiton by ordering international shore fire connections. However, the ATSB recommends the DFES take further action as detailed in the recommendation MO-2014-008-SR-037.

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.

Safety action still pending

BHP Billiton are aligning their checklists with DFES and the WESTPLAN Maritime Transport Emergency (MTE) has recently been rewritten. However, the ATSB recommends DFES take action as detailed in the recommendation MO-2014-008-SR-040.

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.

Safety action still pending

 

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.

Safety action still pending

 

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.

Safety action still pending

 

MO-2014-009 Breakaway of the Grand Pioneer and AAL Fremantle at Fremantle, WA, 17 August 2014

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 impediments to assisting a ship near Wongara Shoal after a breakaway had not been assessed.

Adequately addressed

Fremantle Ports' safety action adequately reduces the possibility of a ship breaking away from the port's inner harbour berths.

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'.

Adequately addressed

The undertaking by BoM to use standard terminology in marine weather forecasts should prevent a forecast being misunderstood. The formal consultative forums will also help in this regard while continuing to improve BoM's product delivery and meeting the needs of the end users of its forecasts and warnings.

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 others were not monitored for compliance.

Adequately addressed

Fremantle Ports' safety action includes procedures, systems and equipment that will allow it to better manage adverse weather events.

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.

Adequately addressed

Fremantle Ports' revised procedures, in combination with the new weather information system and equipment, will allow the port to better manage adverse weather events.

MO-2014-01 Man overboard fatality from Cape Splendor, Port Hedland, WA, 6 October 2014

MO-2014-011-SI-01: Cape Splendor's safety management system (SMS) procedures for working over the side of the ship were not effectively implemented. As a result, the ship's crew routinely did not take all the required safety precautions when working over the side. Further, they did not consider that any such precautions were necessary if going over the side when not working.

Adequately addressed

The safety action taken should reduce the risk of a similar accident and assist in improving the safety culture on U-Ming Marine Transport ships. The action should better assist the effective implementation of SMS procedures for working over the side and/or at heights, including safe practices during recreational activities.

MO-2014-011-SI-02: The safety culture on board Cape Splendor was not well developed and the ship's managers had identified it as such. A consequence of this inadequacy was the ineffective implementation of working over the side procedures, including the general belief by its crew that safe work practices applied only when working, and not during recreational activities.

Adequately addressed

U-Ming Marine Transport has identified the importance of continuing to develop the safety culture on board its ships and across the organisation. This has been promulgated across its fleet through safety circulars and the internal auditing system, which will support a positive safety culture to develop over time. The ATSB has issued the safety advisory notice, MO-2014-011-SAN-024, to promulgate this safety issue more broadly across industry.

MO-2014-012 Fire on board the livestock carrier Ocean Drover, Fremantle, WA, 9 October 2014

MO-2014-012-SI-01: Ocean Drover's bridge deck stairwell fire door was fitted with a holdback hook in contravention of international regulations. The door was hooked open, which allowed the fire to spread up to the bridge deck from the deck below.

Adequately addressed

Proactive safety action taken complies with regulations. The actions taken will prevent this fire door from being latched open in the future.

MO-2014-012-SI-02: The smoking policy and associated risk controls on board Ocean Drover were not effectively managed. While use of designated smoking rooms was identified as the preferred option, smoking was permitted in cabins. In addition, approved ashtrays were not always used to extinguish and dispose of cigarettes.

Adequately addressed

Proactive safety action taken, including: smoking policy updated; designated smoking areas implemented, not including cabins; all accommodation cabins fitted with smoke detectors.

Table 9: Rail—Responses to safety issues identified in 2015–16 news Links

SAFETY ISSUE

STATUS

STATUS JUSTIFICATION

RO-2013-020 Derailment of locomotive and wagon during main line shunting South Dynon Junction, West Melbourne, Victoria, 25 July 2013

RO-2013-020-SI-01: The placement of the insulated rail joints adjacent to signal DYN150 was not in accordance with the ARTC engineering procedure ESC-07-01.

Adequately addressed

The ATSB is satisfied that the action taken by the ARTC addresses this safety issue.

RO-2013-020-SI-02: The practice of using a third party (the shunt planner) to facilitate communication between Network Control Officers and train drivers at the Melbourne Freight Terminal, prevented an effective response to the emergency.

Adequately addressed

The ATSB is satisfied that the action taken by Pacific National addresses this safety issue.

RO-2013-026 Derailment of freight train 3XW4 Newport, Victoria, 30 October 2013

RO-2013-026-SI-01: When the AK Car was operating in manual mode, the methods used to identify the location of a defect and assist track staff to locate the defect could be ineffective in certain scenarios. At the derailment location, there was a consistent offset of about 58 m between the recorded location of the wide-gauge defect and its actual location due to the presence of a 'long kilometre'.

Safety action pending

The development of a GPS-based system that is effective in areas that include long and short kilometres and changes in kilometre count direction should improve the reliability of defect location information.

RO-2013-026-SI-02: Track patrol processes were ineffective at detecting and remedying the wide-gauge defect at the derailment location. Track patrols were overly reliant on the AK Car geometry recording vehicle to trigger maintenance action on this track geometry defect.

Adequately addressed

The additional training and audit activity should improve measurement of track gauge and compliance with network maintenance requirements of track patrols.

RO-2013-026-SI-03: The ARTC response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October 2013.

Adequately addressed

ARTC has taken safety actions to address the recommendation and safety issue.

RO-2013-026-SI-04: ARTC processes for managing the condition of the rail were ineffective despite repeated recording of rail head wear by the AK Car, and local knowledge of the worn rail. The rail was worn beyond the rail condemning limits specified within the network code of practice.

Adequately addressed

Improved asset management policy and planning, combined with local verification of rail wear, should reduce the likelihood of rail wear exceeding condemning limits.

RO-2014-001 Derailment of Sydney Trains Passenger Train 602M Near Edgecliff station, Sydney, New South Wales, 15 January 2014

RO-2014-001-SI-01: Drivers are desensitised to the wheel slip protection indicator light activations through its regular activation in response to momentary losses of adhesion. This, coupled with the inadequate warning provided by the TMS, may result in delayed reaction in response to activations that need driver intervention.

Safety action still pending

At the time of this report release, the safety actions advised by Sydney Trains had not yet been fully implemented. The ATSB is satisfied that the actions proposed by Sydney Trains will, when completed, adequately address this safety issue.

RO-2014-001-SI-02: Reporting and communications were not carried out in accordance with Sydney Trains rules and procedures, so that key employees in the Rail Management Centre received delayed and/or partial information and allowed the train to continue in service.

Safety action still pending

At the time of this report release, the safety actions advised by Sydney Trains had not yet been fully implemented. The ATSB is satisfied that the actions proposed by Sydney Trains will, when completed, adequately address this safety issue

RO-2014-001-SI-03: Key staff had not been trained in Rail Resource Management.

Safety action still pending

At the time of the report release, ATSB considers that further actions could be taken to provide suitable RRM training for employees.

RO-2014-001-SI-04: The lack of an appointed Officer in Charge of the incident site, prior to the arrival of an Incident Rail Commander, led to a fragmented response with no single employee having a recognised leadership role on site.

Safety action still pending

At the time of the report release, ATSB considers Sydney Trains proactive safety action does not fully address the safety issue.

RO-2014-005 Fatality at Heyington railway station, Toorak, Victoria, 22 February 2014

RO-2014-005-SI-01: As designed, the traction interlock deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.

Safety action pending

ATSB accepts Metro Trains Melbourne's (MTM) proposed actions on this safety recommendation. However, until the proposed circuit modifications are completed, the ATSB will retain the status of this safety issue as 'pending'.

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.

No longer relevant

Given the circuit modification and provision of a manual key operated switch described in response to Action number: RO-2014-005-SR-030, this action is no longer applicable.

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.

Adequately addressed

MTM has developed a design practice note to address safety issue.

RO-2014-005-SI-04: Due to the curvature of the track, a wide gap existed between the platforms and trains 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 with respect to safe accessibility.

Safety action pending

ATSB accepts MTM's proposed actions on this safety recommendation. However, until the proposed works are completed at platforms identified as presenting higher risk, the ATSB will retain the status of this safety issue as 'pending'.

RO-2014-007 Derailment of train 3WB3 Nambucca Heads, New South Wales, 14 May 2014

RO-2014-007-SI-01: The Pacific National freight loading manual, and application of it, was ineffective at preventing load shift of rod-in-coil product.

Adequately addressed

Pacific National have engaged consultants to identify and recommend any changes to the freight loading manual and continue to monitor load shifts with the aim to prevent reduce occurrences.

RO-2014-014 Derailment of train 6DA2 near Marryat, South Australia, 26 July 2014

RO-2014-014-SI-01: The scheduled ultrasonic tests conducted, in November 2013 on the 80 lb/yd rail between Northgate and Alice Springs had been ineffective in detecting and quantifying the significant defects present at 1036.541 km and 975.244 km locations.

Adequately addressed

The ATSB is satisfied that the action taken by Genesee & Wyoming Australia (GWA) addresses this safety issue.

RO-2014-014-SI-02: Contrary to the requirements of procedure IN-PRC-020, GWA had not established a list of specific locations known to have an increased likelihood of failure, such that particular attention may be applied in those locations during inspections.

Safety action still pending

RO-2014-018 Derailment of train 5DD2 Thevenard, South Australia, 23 October 2014

RO-2014-018-SI-01: Track defect monitoring and reporting was not being conducted, as specified in the Westrail Narrow Gauge Mainline Code of Practice, limiting the awareness of the deteriorating track condition and the need for reassessment of track operating limits.

Adequately addressed

The ATSB is satisfied that the actions taken by Transfield Services will adequately address this safety issue.

RO-2014-018-SI-02: The rail transport operator (GWA) had not maintained sufficient oversight of the activities of the rail infrastructure manager (Transfield Services), allowing the track to deteriorate to a level where trains could not be run in a safe manner

Adequately addressed

The ATSB is satisfied that the actions taken by Genesee & Wyoming Australia will adequately address this safety issue.

RO-2014-021 Incident Involving Absolute Signal Blocking, Warnervale, New South Wales, 24 November 2014

RO-2014-021-SI-01: There was a breakdown in the NCO handover process used at Morisset, which resulted in ASB being granted to the Protection Officer at Warnervale without the exact location of trains being properly established, signals V8 and V6 being set back to stop and blocking facilities applied in accordance with Network Rule NWT 308.

Adequately addressed

Sydney Trains' coded ASB trial has continued while Sydney Trains prepare for full implementation. In order to fully implement coded ASB rule changes and consultation are required. The development of the rules is underway and consultation will follow. The ATSB recognises Sydney Trains' continued action on this issue by way of assessing and implementing a 'coded Absolute Signal Blocking process' and is satisfied that this process will improve how parties confirm the ID and current location of the last train to pass the protecting signals and result in the lowering of risk associated with worksite protection by ASB. On the basis therefore, that Sydney Trains remain committed to implementing a new (Coded) ASB rule/procedure, the ATSB has re-assessed the status of this issue and has formally closed it as 'Adequately addressed'.

RO-2014-022 Load shift collision between train 2MP9 and road over rail bridge, 227 km near Great Western Loop, Victoria, 9 December 2014

RO-2014-022-SI-00: SCT Logistics' freight loading procedures did not specifically provide for the restraint and securement of double-stacked commercial road transport vehicles for transportation on rail vehicles.

Safety action still pending

 

RO-2014-022-SI-00: SCT Logistics' maintenance processes and systems did not detect the wagon's side bearer faults or ensure that life-limited components were replaced in a timely manner.

Safety action still pending

 

RO-2014-024 Collision between passenger train and truck Woodvale, Victoria, 19 December 2014

RO-2014-024-SI-01: V/Line's process for the inspection of level crossing sighting did not provide explicit instructions for the identification and removal of problem vegetation.

Adequately addressed

The ATSB is satisfied that the actions proposed by V/Line Pty Ltd will, when fully implemented, adequately address this safety issue.

RO-2015-002 Collision between track worker and passenger train at Guildford, Western Australia, 10 February 2015

RO-2015-002-SI-01: The Public Transport Authority of Western Australia did not have any documented work instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment.

Adequately addressed

The ATSB is satisfied that the actions taken by the Public Transport Authority of Western Australia significantly reduces the safety risk, and when combined with completion of the additional training should fully address this safety issue.

RO-2015-003 Passenger train collision with maintenance equipment, Montgomery, near Sale, Victoria, 16 February 2015

RO-2015-003-SI-01: There were no formal systems in place to manage the accepted practice of Protection Officers leaving a worksite to return a Track Warrant and Train Staff, prior to ceasing work, off-tracking and ensuring the line was clear. This practice led to the informal delegation of responsibility for ensuring the track was clear to others at the work site.

Adequately addressed

The ATSB is satisfied that the actions taken by V/Line following this incident, combined with other actions under way (refer additional safety actions), will reduce the risk of track maintenance equipment remaining on track when Track Force personnel are clearing a line for the passage of rail traffic.

RO-2015-00 Wrong running direction involving passenger train 165-S Mt Druitt, New South Wales, 12 March 2015

RO-2015-005-SI-01: Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver.

Safety action pending

RO-2015-007 Collision between freight trains 2MP9 and 2MP1 Mile End, South Australia, 31 March 2015

RO-2015-007-SI-01: Vegetation and a low fence adjacent to the Mile End crossing loop partially obscured the view that the crew of train 2MP9 had of the empty flat wagons at the rear of train 2MP1.

Adequately addressed

The ATSB considers greater proactive action should be taken by the Australian Rail Track Corporation (ARTC) to resolve this safety issue.

RO-2015-007-SI-03: The practice of pathing a following train onto a line occupied by a preceding train, when an alternate route was available and not obstructed, presented an elevated level of risk.

Adequately addressed

The ATSB is satisfied that the actions proposed by the ARTC, for maximising the use of available and suitable infrastructure will reduce the risk of this type of safety issue.

RO-2015-007-SI-04: The practice of pathing a following train onto the same line occupied by a preceding train, without pre-warning the driver regarding the train ahead, presented an elevated level of risk.

Adequately addressed

The ATSB is satisfied that the actions proposed jointly by the ARTC and SCT Logistics will reduce the risk of this type of safety issue.

RO-2015-007-SI-05: The design of the National Train Communications System in screening Adelaide metro broadcast communications prevented the driver of 2MP9 from gaining an appreciation of activities close to his area of operation, in particular the position of train 2MP1 along the Mile End main line.

Safety action pending

At the time of this report release, the safety action advised by the ARTC was yet to be fully implemented.

RO-2015-010 Derailment of track maintenance vehicles Singleton, New South Wales, 11 June 2015

RO-2015-010-SI-01: The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display.

Adequately addressed

The ATSB is satisfied that the actions taken by ARTC will adequately address this safety issue.

RO-2015-010-SI-02: The ARTC Local Appendix Unit North–Volume 3 did not reflect current equipment installation arrangements for E Frame at Singleton.

Adequately addressed

The ATSB is satisfied that the actions taken by ARTC will adequately address this safety issue.

RO-2015-015 Derailment of loaded Pacific National coal service MB520 near Pangela, New South Wales, 28 August 2015

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.

Safety action still pending

 

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.

Adequately addressed

The ATSB is satisfied that the safety action taken by Pacific National will address the safety issue.

Safety actions

Table 10: Number of safety actions released in 2015–16 news Links

SAFETY ACTION TYPE

AVIATION

MARINE

RAIL

TOTAL

Proactive safety action

31

16

22

69

Safety Advisory Notice

0

3

0

3

Safety recommendation

5

6

14

25

Total

36

25

36

97

ATSB recommendations closed in 2015–16 news Links

Aviation—ATSB recommendations closed in 2015–16

There were no aviation safety recommendations closed in 2015–16.

Table 11: Marine—ATSB recommendations closed in 2015–16 news Links

Investigation

MI-2010-011 Independent investigation into Queensland Coastal Pilotage

Safety issue

Risk identification and mitigation in coastal pilotage is inadequate as a result of the under-reporting of risk events and incidents by pilots. Indicators of the inadequacies in risk management and/or under-reporting amongst the 82 pilots surveyed included:

  • significant under-reporting where the number of grounding or collision risk events claimed by pilots in 2010 was about 10 times the number included in Australian Maritime Safety Authority (AMSA) and pilotage provider incident records
  • pilots citing reasons for under-reporting being personal disadvantage, lack of corrective action taken, no risk reduction and remuneration
    risk/organisational pressure
  • no process to record and analyse informal reports made by pilots to AMSA.

Number

MI-2010-011-SR-054

Organisation

Hydro Pilots

Recommendation

The ATSB recommends that Hydro Pilots takes safety action to address the safety issue and facilitate action taken by AMSA to address this issue.

Released

24 October 2012

Final action

1 February 2016

Final action

Hydro Pilots advised ATSB as follows:

Hydro Marine Pilots as part of the larger Aviator Group operate a 'just culture' to create a safe and fair workplace. The safety or our employees, customers and contractors are our number one priority. The safety and efficiency of our operations are mutually supportive and are achieved through a commitment to continuous improvement.

Under our Standard Operating Procedures we clearly state the requirements for the reporting of incidents and hazards that could impact on navigation or the environment:

Incident and Reports during the Voyage:
Pilots must be aware of and comply with all applicable laws, rules and regulations including relevant international conventions and any shipboard safety instructions. Pilots are obligated to report to the appropriate authority any concerns regarding any potential hazards to navigation or the environment. It should be noted that Australian legislation provides significant penalties for failing to comply with any reporting requirements.'

Hydro Marine Pilots support all pilots in encouraging the reporting of any event without fear of penalty. We do not support the assumption that the lack of reports is indicative of a poor safety culture. Unlike the other two pilotage providers, Hydro Marine Pilots only operate within the compulsory area of Hydrographers Passage. As a provider, we engage with our marine pilots face to face on a daily basis due to the location of our operations whereby our pilots are carried by our own helicopter. Discussions on the conduct of the pilotage are frequent with our marine pilots when they disembark the vessel. Our culture is one of inclusion with a shared responsibility for safety.

Investigation

MI-2010-011 Independent investigation into Queensland Coastal Pilotage

Safety issue

Risk identification and mitigation in coastal pilotage operations is inadequate as a result of the under-reporting of risk events and incidents by pilots. Indicators of the inadequacies in risk management and/or under-reporting amongst the 82 pilots surveyed included:

  • significant under-reporting where the number of grounding or collision risk events claimed by pilots in 2010 was about 10 times the number included in AMSA and pilotage provider incident records
  • pilots citing reasons for under-reporting being personal disadvantage, lack of corrective action taken, no risk reduction and remuneration
    risk/organisational pressure
  • no process to record and analyse informal reports made by pilots to AMSA.

Number

MI-2010-011-SR-056

Organisation

Torres Pilots

Recommendation

The ATSB recommends that Torres Pilots takes safety action to address the safety issue and facilitate action taken by AMSA to address this issue.

Released

24 October 2012

Final action

25 January 2016

Final action

Torres Pilots (TP) provided updates on 27 November 2015 and 25 January 2016. These updates, in part, repeated previous commentary that TP had submitted during the investigation and after the final investigation report was published. The following summarises the main points of the recent updates.

Torres Pilots repeated its partial rejection of ATSB's findings on risk event and incident reporting, stating that it does not accept that there was a tenfold underreporting of incidents. Torres Pilots also repeated its concerns about AMSA's approach to incident reporting and related matters, citing a recent example to support its view. These ongoing TP concerns have been reported in its previous responses, as published and detailed in the investigation report. However, TP's update also stated that since the ATSB investigation, 'AMSA's governance of coastal pilotage has markedly improved'.

In terms of safety action to address the safety issue, TP advised that it has appointed a dedicated safety management system, risk, and compliance manager. The manager's duties include a focus on risk event and incident reporting matters. This update also repeated safety action listed in TP's previous update. Supporting evidence, such as TP's non-compliance register summary, was not provided on this occasion.

Investigation

MI-2010-011 Independent investigation into Queensland Coastal Pilotage

Safety issue

The coastal pilot fatigue management plan is inadequate. Factors that limit the effectiveness of the fatigue management plan amongst the 82 pilots surveyed included the:

  • largely self-managed approach where individual pilots may have conflicting priorities relating to remuneration and other working arrangements
  • pilot travel and transfer times regularly being included in rest periods
  • variations in sleep patterns due to irregular working hours and the effect of multiple, consecutive pilotages not being taken into account
  • dispensations being granted from requirements and, when granting dispensations, the pilot's agreement being used to support the fatigue risk assessment despite a clear conflict of interest with the pilot's remuneration
  • lack of effective measures to ensure that fatigue during a single-handed pilotage, particularly in the Inner Route, never exceeds an acceptable level.

Number

MI-2010-011-SR-050

Organisation

Australian Maritime Safety Authority (AMSA)

Recommendation

The ATSB recommends that AMSA takes further safety action to address the safety issue with regard to the high level of fatigue risk involved in single-handed pilotage through the Inner Route of the Great Barrier Reef.

Released

24 October 2012

Final action

1 February 2016

Final action

AMSA advised ATSB as follows:

The fatigue management arrangements detailed in the existing default fatigue risk management plan (FRMP) were developed in consultation with independent subject matter experts (SMEs), including the Centre for Sleep Research, University of South Australia. The fundamental concept of the FRMP is to deliver effective fatigue management arrangements for coastal pilots, based on relevant science and SME input which reinforces the FRMP. The effectiveness of the current FRMP is evidenced by a number of factors, including:

  • marine incident statistics involving vessels under pilotage (i.e. there have been no coastal pilotage related marine incidents reported to AMSA where fatigue has been identified as a contributing factor since the establishment of the FRMP as a regulatory requirement for coastal pilots and pilotage providers)
  • wide-spread acceptance and support for the plan by licensed pilotage providers and extremely high levels of compliance by individual pilots
  • indications received from coastal pilots regarding the effectiveness of the FRMP (as part of annual FRMP effectiveness review procedures where input is sought).

It should be noted that it is a condition of both an individual pilot's licence and a pilotage provider's licence to ensure the fatigue management requirements detailed in the FRMP (or an alternative AMSA-approved fatigue management plan) are complied with.

Whilst the default FRMP does incorporate the concept of individual pilots self-assessing their level of fatigue so as to protect a pilot's capacity to decline work, the primary responsibility for ensuring pilots do not exceed minimum rest periods lies with providers. As a condition of a pilotage provider licence, a provider is required to ensure that pilots comply with the terms of the default FRMP (or an alternative AMSA-approved fatigue management plan).

Marine Order 54 (Coastal pilotage) 2014 (MO54) requires a pilotage provider to have a safety management system (SMS). It is a mandatory requirement that the SMS describes, to AMSA's satisfaction, how the provider's work practices are conducted safely and how the provider complies with the applicable FRMP. AMSA conducts compliance audits on providers in accordance with the provisions of MO54. These compliance audits specifically include an assessment of the provider's compliance with all fatigue management requirements.

The regulatory arrangements outlined above are considered to provide appropriate guidance and incentives to pilotage providers to ensure compliance with the FRMP requirements in order to ensure the provider's licence is not jeopardised as a result of potential systemic non-compliance with fatigue management provisions.

Online fatigue management training and assessment has also been reviewed and implemented by AMSA for the benefit of coastal pilots (AMSA Fatigue Management e-Learning Course). The course is designed to provide pilots with focussed information on the unique challenges and realities of fatigue and personal fatigue management in their working environment. Completion of this course is a mandatory requirement for the issue of a (Restricted) coastal pilot's licence and a certificate is issued upon successful completion.

As provided previously, AMSA approached the market via a 'request for quotation' for the conduct of possible coastal pilot fatigue field assessment. Subsequently, due to the prohibitive costs quoted, AMSA has not pursued this further.

Investigation

MI-2010-011 Independent investigation into Queensland Coastal Pilotage

Safety issue

The coastal pilot training program and ongoing professional development is inadequate. Factors that limit the effectiveness of the training program and ongoing professional development include the:

  • absence of a pilotage safety management system for trainees to learn standard, risk-analysed pilotage procedures and practices, consistent with best practice
  • training program's 'self-learning' approach by observing different systems and practices of pilots that promulgates non-standard systems when trainees develop individual piloting systems increases the potential for sub-optimal practices
  • bridge resource management training that is not backed up with a focus on systems-based risk management through standard procedures and systems by using all resources, such as the coastal vessel traffic service's capability
  • absence of coastal pilotage focused bridge simulator training to augment practical shipboard training.

Number

MI-2010-011-SR-049

Organisation

AMSA

Recommendation

The ATSB recommends that AMSA takes further safety action to address the safety issue with regard to the acquisition of local area knowledge, particularly in confined areas, and the use of electronic charting systems by pilots. Focused training and assessments in bridge simulators should be amongst the measures used to achieve competency levels appropriate for coastal pilots.

Released

24 October 2012

Final action

1 February 2016

Final action

AMSA advised ATSB as follows:

As of the end of January 2016, 100 per cent of active AMSA-licensed coastal pilots had completed requisite electronic chart display and information system (ECDIS) training.

The concept of coastal pilot training and continuing professional development (CPD) is an area that undergoes continual review, development and improvement. This is in consultation with pilots, pilotage providers and training institutions.

AMSA intends to include discussion on the value of simulation training in the coastal pilotage context at the next Coastal Pilotage Training Working Group (CPTWG). Additionally, CPD will also be discussed as a high priority at CPTWG, noting that, as a level of self-regulation, CPD is being deliberated within representative pilotage societies—as highlighted at the October 2015 Pilotage and Port Logistics Conference in Sydney.

AMSA has recently developed examination guidance information for trainee pilots, which includes relevant references to nautical publications, and resources that may assist with the relevant pilotage.

Investigation

MO-2014-001 Serious injury on board the passenger ship Seven Seas Voyager, Sydney, NSW, 1 February 2014

Safety issue

Seven Seas Voyager's planned maintenance system (PMS) contained no information about waste incinerator ash grate replacement, a task that would have been regularly undertaken by different engineering staff since 2003. Therefore, in this respect, the shipboard procedures that documented requirements for the PMS had not been effectively implemented.

Number

MO-2014-001-SR-001

Organisation

Prestige Cruise Services

Recommendation

The ATSB recommends that Prestige Cruise Services take action to ensure that all shipboard repetitive non-routine maintenance activities are addressed and appropriately documented within the ship's planned maintenance system.

Released

23 January 2015

Final action

29 July 2015

ATSB response

The ship's planned maintenance system incinerator work order has been amended to provide specific instructions about the equipment's components. In addition, the revised monthly inspection routine for the incinerator will increase crew familiarity and understanding of the system and work requirements.

Table 12: Rail—ATSB recommendations closed in 2015–16 news Links

Investigation

RO-2012-006 Collision between two road-rail vehicles Haig, Western Australia, 24 May 2012

Safety issue

The absence of a national standard that addresses the design, fitment and maintenance of rail guidance equipment and the safety performance for road-rail vehicles while on-rail, increases the risks associated with operating road-rail vehicles.

Number

RO-2012-006-SR-018

Organisation

Rail Industry Safety and Standards Board (RISSB)

Recommendation

The ATSB recommends that the Rail Industry Safety Standards Board continue to progress the timely development of a standard to address this safety issue.

Released

15 September 2014

Final action

15 June 2016

Final action

RISSB has published AS7502 Road Rail Vehicles

Investigation

RO-2013-008 Level crossing collision between passenger train and semi-trailer near Lake Charm, Victoria, 12 February 2013

Safety issue

There existed an inconsistency between the track speed used for crossing assessment and permitted train speeds. The ALCAM process used a train speed equal to the track line speed, whereas V/Line systems for evaluating driver behaviour permitted an exceedance of line speed by up to 10 km/h for short distances.

Number

RO-2013-008-SR-074

Organisation

VicTrack

Recommendation

The Australian Transport Safety Bureau recommends that VicTrack takes action to address the inconsistency that exists between the crossing assessment that assumes a train travelling at line speed, and the sighting that would be required for a train travelling at the 10 km/h greater speed that is procedurally permitted by the rail operator.

Released

7 October 2014

Final action

20 July 2015

Final action

The ALCAM Committee will issue advice to rail stakeholders supplying data into the ALCAM database that 'Maximum Train Speed' should be the highest allowed train speed at that location taking into account permanent speed restrictions or extreme grades.

Investigation

RO-2013-008 Level crossing collision between passenger train and semi-trailer near Lake Charm, Victoria, 12 February 2013

Safety issue

When the crossing was last surveyed under the ALCAM program, the measurement of the road angle resulted in an overestimate of the acute road-to-rail interface angle. The implication of overestimating the acute interface angle is that sighting deficiencies may be underestimated or not identified.

Number

RO-2013-008-SR-071

Organisation

VicTrack

Recommendation

The Australian Transport Safety Bureau recommends that VicTrack reviews its instructions for the measurement of road angle to assure that worst case sighting scenarios are identified.

Released

7 October 2014

Final action

20 July 2015

Final action

The ALCAM Committee will make changes to the Crossing Assessment Manual to highlight that surveyors are to base sighting distance measurement on a worst reasonable case vehicle path, and this advice will be included within the curriculum for future ALCAM field collection training.

Investigation

RO-2013-017 Safeworking breach involving a Local Possession Authority, Revesby, New South Wales, 10 July 2013.

Safety issue

There were non-compliances to the repeat back provision because it was viewed as onerous under certain Local Possession Authorities (LPAs). An opportunity exists to review rule non-conformance with the implementation of LPAs.

Number

RO-2013-017-SR-055

Organisation

Sydney Trains

Recommendation

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

Released

19 September 2014

Final action

21 September 2015

Final action

Sydney Trains stated:

The Manager Network Rules & Projects has listened to and reviewed audio recordings from 12 randomly selected LPAs in relation to the transaction between Train Controllers, Signallers and PPOs when requesting and authorising LPA's. He determined that in all instances a read back process was followed. However, the conversations were undertaken with varying levels of quality and accuracy.

Sydney Trains' Network Operations Division has commenced a 'Safety Critical Communications Project', sponsored by the Director Operations and managed by the Manager Operations Compliance and Assurance. The aim of the project is to improving safety critical communications on the Network through more extensive monitoring, review and feedback to staff regarding safety critical communications. The project will also include a review of the existing Network Standard and Network Rules and Procedures relating to safety critical communications and an improved training and coaching regime. The focus of the project will be the reading back of safety critical communication and the training of Signallers and Train Controllers to take the lead in these conversations, especially in relation to prompting and leading the read back process.

The Australian Transport Safety Bureau is satisfied that the action taken by Sydney Trains has adequately addressed the safety issue.

Investigation

RO-2013-018 Safeworking breaches involving Absolute Signal Blocking at Blackheath on 13 June 2013, Newcastle on 13 July 2013 and Wollstonecraft on 17 July 2013

Safety issue

The Sydney Trains regime for auditing worksite protection arrangements was not effective in identifying emerging trends or safety critical issues, when using Absolute Signal Blocking (ASB).

Number

RO-2013-018-SR-085

Organisation

Sydney Trains

Recommendation

The ATSB recommends that Sydney Trains undertake further work to ensure that future auditing of worksite protection arrangements is effective in identifying issues with the implementation and use of Absolute Signal Blocking as a method of safeworking.

Released

2 March 2015

Final action

23 September 2015

Final action

Sydney Trains provided extra detail on the worksite protection auditing, both undertaken and proposed, to address the recommendation RO-2013-018-SR-085. Three documents were attached in support of information in their response. In their response, Sydney Trains stated:

Sydney Trains undertakes compliance audits of worksites within the rail corridor, specifically targeting the application of Absolute Signal Blocking (ASB) work on track method (where possible). As the audits are unannounced, and ASB does not require significant pre-notice, the audits will not always find ASB worksites. The audits are known as Application of Worksite Protection Audits and are conducted through onsite interviews, verification of worksite protection plans/pre-work briefs against Sydney Trains Network Rules and Procedures and other requirements under the Sydney Trains Rail Corridor Safety Program. Sydney Trains' Network Rules and Procedures, specifically the Work on Track Rules, prescribe the requirements for undertaking activities in the rail corridor and mandate the ways to plan for and achieve the separation of rail traffic from people working on or about track.

The audits are undertaken two days per month and include randomly selected worksites, within the danger zone, on the Sydney Trains network. All worksites which are encountered by the audit team within the rail corridor are audited to assess the level of conformance to Sydney Trains Network Rules and procedures. A detailed audit checklist specifically aligned to the application of the criteria for ASB is utilised by the audit team in the field. The requirements for Coded ASB, currently under trial within Sydney Trains, will be incorporated into the audit checklist tool once the process is formally implemented into the Network Rules and Procedures.

The audit schedule is determined and approved by Group Manager Quality Systems and the audit events are maintained through the Sydney Trains integrated audit management SharePoint site. The audit SharePoint site provides an overview of the audit program for Sydney Trains and provides complete visibility of audit programs for Sydney Trains. It provides detailed information about scope, type, location, auditor, etc. Audit schedule adherence is managed and governed by executive management through the organisational Visual Management Cell (VMC) process and SEQR Audit Working Group meetings.

These audits commenced in April 2015. To date, a total of five Application of Worksite Protection Audits have been completed. The audit team encountered a total of 29 worksites which were undertaking various types of work within the rail corridor during this period. Five of the worksites were applying Absolute Signal Blocking (ASB) work on track method. There were six findings relating to ASB sites. With the exception of the non-conformance identified, all findings were actioned and fully closed out at the time of the audit by mentoring/coaching of the staff by the audit team's Rail Corridor Safety Program Mentor.

The ATSB recognises Sydney Trains' continued action on the associated safety issue by way of implementing a Preliminary Worksite Protection Audit schedule. The ATSB is satisfied that this action taken by Sydney Trains adequately addresses this safety issue.

Investigation

RO-2013-026 Derailment of freight train 3XW4 Newport, Victoria, 30 October 2013

Safety issue

The Australian Rail Track Corporation (ARTC) response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October.

Number

RO-2013-026-SR-101

Organisation

ARTC

Recommendation

The ATSB recommends that ARTC takes safety action to enhance the effectiveness of its response to a derailment event to prevent a similar incident.

Released

13 January 2016

Final action

27 April 2016

Final action

Since the Newport derailment, ARTC has undertaken the following safety actions to address this safety issue:

  • A new position 'Area Safety Advisor' has been created and is located in Melbourne. This position will assist in the investigation of events in Melbourne and supplements other similar positions located in Adelaide and Newcastle.
  • Track management tasks and roles have been clarified. This includes more clearly defined responsibilities for the investigation of a derailment, the production of findings and management responsibilities for ensuring a derailment site is adequately repaired such that a repeat occurrence does not occur.
  • The introduction of a new system to track and review all incidents, improving the robustness of this process compared to that in place prior to the Newport derailment.

Investigation

RO-2014-007 Derailment of train 3WB3 Nambucca Heads, New South Wales, 14 May 2014

Safety issue

The Pacific National freight loading manual, and application of it, was ineffective at preventing load shift of rod-in-coil product.

Number

RO-2014-007-SR-036

Organisation

Pacific National Pty Ltd

Recommendation

The Australian Transport Safety Bureau recommends that Pacific National undertake further work to address the possibility that rod-in-coil product could shift during transit, thereby creating an undesirable condition that could affect the dynamic behaviour of the vehicle.

Released

23 September 2015

Final action

22 December 2015

Final action

Pacific National is carrying out/proposing to carry out the following actions:

  1. Pacific National (PN) Assets and Infrastructure Services has engaged a consultant to conduct an audit of PN procedures and operational processes, relating to the development and implementation of the Freight Loading Manual (FLM). This analysis involved performing a gap analysis in relation to current steel loading processes. The key focus of this work is to review processes relating to steel services within and ex-Newcastle (Morandoo terminal). This will provide a good overview of the application of the FLM across all major loading locations. The scope of the work includes the interfaces and processes between customers, the Freight Loading Manual (Engineering) and the PN Operations group. The following specifics are within phase one of the work:
    • a study of the steel loading processes for Morandoo only
    • a review of the Freight Loading Manuals (FLMs) and guidelines
    • an inspection regime post–loading—how PN ensures compliance against the FLMs if work is undertaken by a third party
    • development of a load assessment tool
    • identification of any recommendations.
  2. If further information can be obtained, PN will a complete the dynamic modelling and continue to identify the root cause determination.
  3. Pacific National will continue to monitor the occurrence of rod in coil load shifts and investigate why these occur, with the aim being to reduce these occurrences.

Investigation

RO-2014-021 Incident involving Absolute Signal Blocking, Warnervale, New South Wales, 24 November 2014

Safety issue

There was a breakdown in the NCO handover process used at Morisset which resulted in ASB being granted to the Protection Officer at Warnervale without the exact location of trains being properly established, signals V8 and V6 being set back to stop and blocking facilities applied in accordance with Network Rule NWT 308.

Number

RO-2014-021-SR-021

Organisation

Sydney Trains

Recommendation

The ATSB recommends that Sydney Trains takes further action to expedite the implementation of safeguards and procedural safety enhancements where Absolute Signal Blocking is to be used for worksite protection.

Released

17 September 2015

Final action

14 September 2015

Final action

Sydney Trains stated:

Sydney Trains agrees with safety recommendation RO-2014-021-SR-021. The safety action being undertaken to address this safety recommendation is the implementation of coded ASB. In order to fully implement coded ASB, rule changes and consultation are required. The development of the rules is underway and consultation will follow. At this time it is anticipated that coded ASB will be fully implemented by the end of March 2016.

Safety recommendations released in 2015–16

Table 13: Aviation—Safety recommendations released in 2015–16 news Links

Investigation

AO-2013-100 Landing below minima due to fog involving B737s VH-YIR and VH-VYK, Mildura Airport, Victoria, 18 June 2013.

Safety issue

The automatic broadcast services do not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thereby not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

Number

AO-2013-100-SR-057

Organisation

Airservices Australia

Safety Recommendation

The ATSB recommends that Airservices Australia, as the safety issue owner, works in collaboration with the Bureau of Meteorology to instigate a system change which will reinstate the alerting function of SPECI reports currently not available through an Automatic Broadcast Service.

Released

31 May 2016

Investigation

AO-2013-226 In-flight break-up involving de Havilland DH 82A Tiger Moth, VH-TSG, 300 m east of South Stradbroke Island, Queensland, 16 December 2013

Safety issue

Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life-limits, were appropriately considered.

Number

AO-2013-226-SR-044

Organisation

Civil Aviation Safety Authority

Safety Recommendation

The ATSB recommends that the Civil Aviation Safety Authority takes action to provide assurance that all of the replacement parts that were approved for Australian Parts Manufacturer Approval by the Regulatory Reform Program Implementation team in 2003 have appropriately considered important service factors, such as service history and life limits.

Released

21 January 2016

Investigation

AO-2014-163 Collision with terrain involving One Design DR-107 VH-EGT, near Goolwa SA, 10 October 2014

Safety issue

The Civil Aviation Safety Authority did not require builders of amateur-built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. Without a flight manual the builder, other pilots and subsequent owners do not have reference to operational and performance data necessary to safely operate the aircraft.

Number

AO-2014-163-SR-008

Organisation

Civil Aviation Safety Authority

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority takes safety action to address the lack of a requirement for builders of amateur-built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing.

Released

14 April 2016

Investigation

AR-2013-107 Engine failures and malfunctions in light aeroplanes: 2009 to 2014

Safety issue

Thicker 7/16 inch diameter through-bolts, fitted to newer Jabiru engines and some retro-fitted engines, have had limited service to date to confirm early indications that they reduce this risk. Retro-fitting engines with thicker through-bolts has only been recommended for aircraft involved in flight training by JSB031 issue 3. Most light aircraft in service with Jabiru engines continue to use 3/8 inch diameter engine through-bolts which, even after upgrades in accordance with Jabiru service bulletins JSB031 issues 1 and 2, remain at an elevated risk of fracturing within the service life of the bolt, leading to an engine failure or malfunction in flight.

Number

AR-2013-107-SR-056

Organisation

Civil Aviation Safety Authority

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority continue to monitor the through-bolt failure rate of Jabiru engines to satisfy themselves of the reliability of the:

  • 7/16 inch diameter bolts
  • any other alternative produced to replace the existing 3/8 inch diameter through-bolt configuration (including newly developed through-bolts incorporating aspects to alleviate the effects of thermal expansion and damp resonant vibrations) to determine if these modifications have sufficiently reduced the risk of an engine failure or malfunction in Jabiru-powered aircraft.

Released

9 March 2016

Investigation

AR-2013-107 Engine failures and malfunctions in light aeroplanes: 2009 to 2014

Safety issue

Thicker 7/16 inch diameter through-bolts, fitted to newer Jabiru engines and some retro-fitted engines, have had limited service to date to confirm early indications that they reduce this risk. Retro-fitting engines with thicker through-bolts has only been recommended for aircraft involved in flight training by JSB031 issue 3. Most light aircraft in service with Jabiru engines continue to use 3/8 inch diameter engine through-bolts which, even after upgrades in accordance with Jabiru service bulletins JSB031 issues 1 and 2, remain at an elevated risk of fracturing within the service life of the bolt, leading to an engine failure or malfunction in flight.

Number

AR-2013-107-SR-055

Organisation

Jabiru Aircraft

Safety Recommendation

The Australian Transport Safety Bureau recommends that Jabiru Aircraft Australia takes further safety action to ensure that all owners of Jabiru engines that have not been manufactured with new configuration 7/16 inch diameter through-bolts, or modified in accordance with Jabiru Service Bulletin JSB031-3 have access to, and are encouraged to upgrade to:

  • the 7/16 inch diameter through-bolt configuration, or
  • any other alternative produced to replace the existing 3/8 inch diameter through-bolt configuration (including newly developed through-bolts incorporating aspects to alleviate the effects of thermal expansion and damp resonant vibrations).

Released

9 March 2016

Table 14: Marine—Safety recommendations released in 2015–16 news Links

Investigation

MO-2014-008 Engine room fire on board the bulk carrier Marigold, Port Hedland, WA, 13 July 2014

Safety issue

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.

Number

MO-2014-008-SR-040

Organisation

Western Australian Department of Fire and Emergency Services

Safety Recommendation

The ATSB recommends that the Department of Fire and Emergency Services takes action to address the safety issue with regard to transfer of control procedures for incident controllers from different organisations.

Released

20 April 2016

Investigation

MO-2014-008 Engine room fire on board the bulk carrier Marigold, Port Hedland, WA, 13 July 2014

Safety issue

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.

Number

MO-2014-008-SR-043

Organisation

Western Australian Department of Fire and Emergency Services

Safety Recommendation

The ATSB recommends that the Department of Fire and Emergency Services takes action to address the safety issue with regard to transporting ship firefighting caches to wharves.

Released

20 April 2016

Investigation

MO-2014-008 Engine room fire on board the bulk carrier Marigold, Port Hedland, WA, 13 July 2014

Safety issue

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.

Number

MO-2014-008-SR-041

Organisation

Western Australian Department of Fire and Emergency Services

Safety Recommendation

The ATSB recommends that the Department of Fire and Emergency Services takes action to address the safety issue with regard to safe access to fire and smoke-affected shipboard spaces.

Released

20 April 2016

Investigation

MO-2014-008 Engine room fire on board the bulk carrier Marigold, Port Hedland, WA, 13 July 2014

Safety issue

The limited professional firefighting capability in Port Hedland restricted the ability to launch an effective response to the fire on board Marigold.

Number

MO-2014-008-SR-042

Organisation

Western Australian Department of Fire and Emergency Services

Safety Recommendation

The ATSB recommends that the Department of Fire and Emergency Services takes action to address the safety issue with regard to the professional firefighting capability in Port Hedland and other regional ports.

Released

20 April 2016

Investigation

MO-2014-008 Engine room fire on board the bulk carrier Marigold, Port Hedland, WA, 13 July 2014

Safety issue

Marigold's Halon gas fixed fire suppression system for the engine room was not fully operational–probably as a result of inadequate maintenance. The multiple failures of the system at the time of the fire were not consistent with proper maintenance and testing.

Risk

Significant

Number

MO-2014-008-SR-035

Organisation

Korea Loading Company of Ship Management (KLCSM)

Safety Recommendation

The ATSB recommends that KLCSM takes action to address the safety issue with regard to the maintenance of ships' fixed fire suppression systems to ensure they are fully operational at all times.

Released

20 April 2016

Investigation

MO-2014-008 Engine room fire on board the bulk carrier Marigold, Port Hedland, WA, 13 July 2014

Safety issue

Port Hedland's emergency response teams did not use the ship's international shore fire connection. As a result Marigold's fire main was not pressurised with water from ashore.

Number

MO-2014-008-SR-037

Organisation

Western Australian Department of Fire and Emergency Services

Safety Recommendation

The ATSB recommends that the Department of Fire and Emergency Services takes action to address the safety issue with regard to the appropriate use of international shore connections to pressurise ship fire mains when responding to shipboard fires.

Released

20 April 2016

Table 15: Rail—Safety recommendations released in 2015–16 news Links

Investigation

RO-2013-026 Derailment of freight train 3XW4 Newport, Victoria, 30 October 2013

Safety issue

The ARTC response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October.

Number

RO-2013-026-SR-101

Organisation

ARTC

Safety Recommendation

The ATSB recommends that ARTC takes safety action to enhance the effectiveness of its response to a derailment event to prevent a similar incident.

Released

13 January 2016

Investigation

RO-2014-001 Derailment of Sydney Trains Passenger Train 602M Near Edgecliff station, Sydney, NSW, 15 January 2014

Safety issue

The lack of an appointed Officer in Charge of the incident site, prior to the arrival of an Incident Rail Commander, led to a fragmented response with no single employee having a recognised leadership role on site.

Number

RO-2014-001-SR-026

Organisation

Sydney Trains

Safety Recommendation

The ATSB recommends that Sydney Trains, through a revision to its Incident Management Framework, adopts the positive appointment of an Officer in Charge for Level 2, 3 & 4 incidents once they have been reported. This requirement and the functions of an Officer in Charge must be included in the training of all operational RMC staff and all positions which may be required to adopt this role.

Released

3 December 2015

Investigation

RO-2014-001 Derailment of Sydney Trains Passenger Train 602M Near Edgecliff station, Sydney, NSW, 15 January 2014

Safety issue

Key staff had not been trained in Rail Resource Management.

Number

RO-2014-001-SR-025

Organisation

Sydney Trains

Safety Recommendation

The ATSB recommends that Sydney Trains revisits the recommendation from the Final Report of the Special Commission of Inquiry into the Waterfall Rail Accident Volume 2 viz: Customised human factors training for rail safety workers and management/supervisory level staff based on contemporary Crew Resource Management (now RRM) principles and takes action to ensure that RRM training is rolled out to all employees as categorised in the recommendation and especially RMC staff, and that RRM is embedded into Sydney trains' training and certification processes. To assist in achieving this, it may be useful to benchmark RRM/CRM training and workplace application against both comparable rail operators and also against other high risk industries (such as aviation) both nationally and internationally.

Released

1 March 2016

Investigation

RO-2014-005 Fatality at Heyington railway station, Toorak, Victoria, 22 February 2014

Safety issue

As designed the traction interlock deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.

Number

RO-2014-005-SR-030

Organisation

Metro Trains Melbourne

Safety Recommendation

The ATSB recommends that MTM considers a modification of the traction interlock override system to incorporate additional risk mitigations.

Released

13 July 2015

Investigation

RO-2014-005 Fatality at Heyington railway station, Toorak, Victoria, 22 February 2014

Safety issue

The train door open/close indicator on the driver's control console was inadequate as a warning device once the traction interlock had deactivated.

Number

RO-2014-005-SR-031

Organisation

Metro Trains Melbourne

Safety Recommendation

The ATSB recommends that MTM considers incorporating an additional warning device to heighten driver awareness that the train doors have not closed, if automatic deactivation is retained.

Released

13 August 2015

Investigation

RO-2014-005 Fatality at Heyington railway station, Toorak, Victoria, 22 February 2014

Safety issue

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 platform and train due to track curvature. These gaps pose a risk to passengers with respect to safe accessibility.

Number

RO-2014-005-SR-035

Organisation

Metro Trains Melbourne

Safety Recommendation

The ATSB recommends that MTM expedite their plans to introduce additional risk mitigation measures (such as instituted at Heyington Railway Station) at the platforms that have been identified as presenting higher risks from larger platform-carriage clearances.

Released

27 November 2015

Investigation

RO-2014-007 Derailment of train 3WB3 Nambucca Heads, New South Wales, 14 May 2014

Safety issue

The Pacific National freight loading manual, and application of it, was ineffective at preventing load shift of rod-in-coil product.

Number

RO-2014-007-SR-036

Organisation

Pacific National Pty Ltd

Safety Recommendation

The Australian Transport Safety Bureau recommends that Pacific National undertake further work to address the possibility that rod-in-coil product could shift during transit, thereby creating an undesirable condition that could affect the dynamic behaviour of the vehicle.

Released

23 September 2015

Investigation

RO-2014-014 Derailment of train 6DA2 near Marryat, South Australia, 26 July 2014

Safety issue

Contrary to the requirements of procedure IN-PRC-020, GWA had not established a list of specific locations known to have an increased likelihood of failure, such that particular attention may be applied in those locations during inspections.

Number

RO-2014-014-SR-034

Organisation

Genesee & Wyoming Aust Pty Ltd (GWA)

Safety Recommendation

The Australian Transport Safety Bureau recommends that Genesee & Wyoming Australia undertake further work to address the identification, assessment and recording of special locations on the GWA rail network, in accordance with GWA procedure IN-PRC-020.

Released

28 October 2015

Investigation

RO-2014-016 Collision between V/Line train 8280 and MTM train 6502 at Altona, Victoria, 22 August 2014

Safety issue

The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.

Number

RO-2014-016-SR-039

Organisation

Metro Trains Melbourne

Safety Recommendation

That Metro Trains Melbourne institute measures to ensure that the luminous intensity of marker lights of all passenger trains in their fleet meet a railway industry approved and accepted standard.

Released

2 February 2016

Investigation

RO-2014-016 Collision between V/Line train 8280 and MTM train 6502 at Altona, Victoria, 22 August 2014

Safety issue

The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.

Number

RO-2014-016-SR-038

Organisation

Metro Trains Melbourne

Safety Recommendation

The ATSB recommends that Metro Trains Melbourne consider additional risk mitigation measures to maintain train separation, where the safeworking system allows permissive working.

Released

12 February 2016

Investigation

RO-2014-021 Incident Involving Absolute Signal Blocking, Warnervale, New South Wales, 24 November 2014

Safety issue

There was a breakdown in the NCO handover process used at Morisset which resulted in ASB being granted to the Protection Officer at Warnervale without the exact location of trains being properly established, signals V8 and V6 being set back to stop and blocking facilities applied in accordance with Network Rule NWT 308.

Number

RO-2014-021-SR-021

Organisation

Sydney Trains

Safety Recommendation

The ATSB recommends that Sydney Trains takes further action to expedite the implementation of safeguards and procedural safety enhancements where Absolute Signal Blocking is to be used for worksite protection.

Released

17 September 2015

Investigation

RO-2015-005 Wrong running direction involving passenger train 165-S Mt Druitt, New South Wales, 12 March 2015

Safety issue

Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver.

Number

RO-2015-005-SR-004

Organisation

Sydney Trains

Safety Recommendation

The ATSB recommends that Sydney Trains take safety action to ensure that adequate strategies exist to safeguard against fatigue impairment of train crew called in on the stand-by roster.

Released

29 January 2016

Investigation

RO-2015-007 Collision between freight trains 2MP9 and 2MP1 Mile End, South Australia, 31 March 2015

Safety issue

Vegetation and a low fence adjacent to the Mile End crossing loop partially obscured the view that the crew of train 2MP9 had of the empty flat wagons at the rear of train 2MP1.

Number

RO-2015-007-SR-008

Organisation

ARTC

Safety Recommendation

The ATSB recommends that the ARTC takes action to improve the sighting distances available within the Mile End crossing loop by removing unnecessary vegetation and other obstructions.

Released

16 December 2015

Investigation

RO-2015-015 Derailment of loaded Pacific National coal service MB520 near Pangela, New South Wales, 28 August 2015

Safety issue

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.

Number

RO-2015-015-SR-012

Organisation

Pacific National Pty Ltd

Safety Recommendation

The ATSB recommends that Pacific National take safety action to ensure that adequate wheel inspection standards and systems exist to safeguard against wheel failure.

Released

29 June 2016

Table 16: Marine—Safety advisory notices released in 2015–16 news Links

Investigation

MO-2014-003 Anchor dragging and contact between ships, Fremantle anchorage, 8 May 2014

Safety issue

The International Association of Classification Societies (IACS) recommendation for having a means of slipping the anchor cable bitter outside the chain locker had not been provided on board Royal Pescadores. Further, the ship's classification society, ClassNK, does not consider that the IACS recommended slipping arrangement is necessary for reducing safety risk.

Number

MO-2014-003-SAN-020

Organisation

International Association of Classification Societies

Safety Advisory Notice

The ATSB advises the IACS that it should consider the safety implications of there being no requirement for its members to follow best practice with respect to anchor cable bitter end securing arrangements, consistent with IACS Recommendation No. 10, 1.2.2 (b).

Released

12 October 2015