Date Issue Released
Issue number
Safety issue title
Sydney Trains Security Control Centre Operator procedure contains conflicting instructions on incident response
Safety Issue Description

Sydney Trains Security Control Centre Standard Operating Procedure contained conflicting instructions on incident response, which were not aligned with the Sydney Trains Network Incident Management Plan (NIMP).

Issue Owner
Sydney Trains
Transport Function
Rail: Passenger - metropolitan
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Sydney Trains Security Control Centre Operator unaware CCTV cameras tampered with at Kembla Grange Station
Safety Issue Description

Sydney Trains Security Control Centre Operator was not alerted to tampering of the cameras at Kembla Grange Station that monitored the West Dapto Road Level crossing.

Issue Owner
Sydney Trains
Transport Function
Rail: Operations control
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Rail
Issue number
Safety issue title
Maritime Safety Queensland emergency preparedness
Safety Issue Description

Maritime Safety Queensland (MSQ) did not have structured or formalised risk or emergency management processes or procedures. Consequently, MSQ was unable to adequately assess and respond to the risks posed by the river conditions and current exceeding operating limits and ensure the safety of berthed ships, port infrastructure or the environment, and avoid CSC Friendship’s breakaway. 

Issue Owner
Maritime Safety Queensland
Transport Function
Marine: Shore-based operations
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Marine
Issue number
Safety issue title
Poseidon Sea Pilots preparations for emergency port pilotage
Safety Issue Description

Poseidon Sea Pilots’ (PSP) safety management system for pilotage operations did not have procedures or processes to manage predictable risks associated with increased river flow or pilotage operations outside normal conditions. This, in part, resulted in PSP not considering risks due to the increased river flow properly and not taking an active role until after the breakaway. 

Issue Owner
Poseidon Sea Pilots
Transport Function
Marine: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Marine
Issue number
Safety issue title
Ampol preparations for increasing river current speed
Safety Issue Description

Ampol’s assessment of risk to the ship and facility did not consider water speed in excess of the design and safety limits for the ship and berth mooring arrangements. 

Issue Owner
Ampol
Transport Function
Marine: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Marine
Issue number
Safety issue title
Maritime Safety Queensland emergency preparedness
Safety Issue Description

Maritime Safety Queensland (MSQ) did not have structured or formalised risk or emergency management processes or procedures. Consequently, MSQ was unable to adequately assess and respond to the risks posed by the river conditions and current exceeding operating limits and ensure the safety of berthed ships, port infrastructure or the environment, and avoid CSC Friendship’s breakaway. 

Issue Owner
Maritime Safety Queensland
Transport Function
Marine: Shore-based operations
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Marine
Issue number
Safety issue title
Fatigue risk management system
Safety Issue Description

Likely due to an underlying lack of resources within Airservices Australia, there was an over‑reliance on tactical changes to manage the roster. As a result, cumulative fatigue was not being effectively managed strategically and an over‑reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.

Issue Owner
Airservices Australia
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Fatigue assessment of low workload
Safety Issue Description

Although Airservices Australia’s fatigue assessment and control tool (FACT) had the means of identifying situational factors that influenced fatigue, it had limited effectiveness as supervisors were not identifying low workload as a fatigue hazard. 

Issue Owner
Airservices Australia
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Fatigue risk management system
Safety Issue Description

Likely due to an underlying lack of resources within Airservices Australia, there was an over‑reliance on tactical changes to manage the roster. As a result, cumulative fatigue was not being effectively managed strategically and an over‑reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.

Issue Owner
Airservices Australia
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s procedure to use mixture to simulate engine failure
Safety Issue Description

Fly Oz's asymmetric training procedure involved failing one engine using the mixture control without confirmation the engine was subsequently restarted, rather than reducing throttle to simulate zero thrust in accordance with the Beechcraft E55 Airplane Flight Manual. This increased the risk of undetected asymmetric operation during descent and landing and the associated loss of control.

Issue Owner
Fly Oz
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Risk identification and assessment
Safety Issue Description

The risk assessments conducted by Southern Shorthaul Railroad (SSR) for shunting and banking operations did not include consultation consisting of effective and meaningful engagement with all relevant stakeholders. This increased the potential that risks could be missed during the risk assessment process.

Issue Owner
Southern Shorthaul Railroad (SSR)
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Emergency response to brake pipe pressure loss
Safety Issue Description

Southern Shorthaul Railroad's (SSR's) emergency response procedures did not include requirements for banking locomotive operations.

Issue Owner
Southern Shorthaul Railroad (SSR)
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Coupler instruction, training and assessment
Safety Issue Description

Southern Shorthaul Railroad's (SSR's) training and assessment did not include coupler functionality and the process to ensure correct coupling had occurred. Further, an underpinning procedure for the stretch test (effectively coupled) process did not exist.

Issue Owner
Southern Shorthaul Railroad (SSR)
Transport Function
Rail: Freight
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Rail
Issue number
Safety issue title
Independent checking of works
Safety Issue Description

There was probably no independent check of the isolation arrangements installed on the night of 29 November. An earlier internal audit of the project also reported instances of testers in charge checking their own work. 

Issue Owner
Western Program Alliance (includes Alliance member Metro Trains Melbourne)
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Rail
Issue number
Safety issue title
Guidelines for fuse removal
Safety Issue Description

Metro Trains Melbourne standards and procedures did not specifically address requirements associated with fuse removal and securement in safety critical scenarios. 

Issue Owner
Metro Trains Melbourne
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Rail
Issue number
Safety issue title
Change management
Safety Issue Description

Changed level crossing isolation arrangements were not effectively reflected in program documentation, nor effectively disseminated to all those potentially affected. An earlier internal audit of the project also identified instances of scope changes not being documented.

Issue Owner
Western Program Alliance (includes Alliance member Metro Trains Melbourne)
Transport Function
Rail: Infrastructure
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Rail
Issue number
Safety issue title
Effectiveness of the check pilot system
Safety Issue Description

The check pilot system was ineffective in providing the Australian Maritime Safety Authority (AMSA) assurance of the competency of coastal pilots, mainly due to the inconsistent and unreliable application of assessment standards between different check pilots. Further, AMSA had not implemented a system to identify the inconsistent application of standards or the trends in assessment outcomes readily apparent in the data that it had held for many years.

Response by the Australian Maritime Safety Authority

Issue Owner
Australian Maritime Safety Authority
Transport Function
Marine: Other
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Marine
Issue number
Safety issue title
Threshold visibility
Safety Issue Description

Due to topography and buildings at Mildura Airport, aircraft are not directly visible to each other on the threshold of runway 09, 27 and 36. The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.

Issue Owner
Mildura Airport
Transport Function
Aviation: Airports
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Swissport training and audits
Safety Issue Description

Swissport did not ensure that the implemented training and audits for Link Airways Saab 340B dispatches incorporated all of the elements required in its Ground operations manual for pre‑departure walk-arounds.

Issue Owner
Swissport
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Link training guidance lacked details regarding propeller straps
Safety Issue Description

Guidance provided by Link Airways for training of Swissport dispatch coordinators did not explain the appearance, function and importance of the propeller straps.

Issue Owner
Link Airways
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation