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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Southern Shorthaul Railroad's (SSR's) emergency response procedures did not include requirements for banking locomotive operations.
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.
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.
Metro Trains Melbourne standards and procedures did not specifically address requirements associated with fuse removal and securement in safety critical scenarios.
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.
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
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.
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.
Guidance provided by Link Airways for training of Swissport dispatch coordinators did not explain the appearance, function and importance of the propeller straps.