ARTC did not reliably identify, monitor and analyse recurring track defects which resulted in a reduced capability to:
While ARTC had a process for monitoring its maintainers when carrying out inspections and rectifications, it was unable to provide evidence of these activities being conducted.
The Brisbane Airport Corporation training material and in-cab instructions did not state that operators must gain and maintain visibility of aircraft from the home position, before moving the aerobridge.
Sydney Trains did not have a response process for overspeed incidents.
Response by Sydney Trains
Sydney Trains has existing processes to respond to incidents involving trains / track infrastructure. Following this incident when it was identified that the involved train was allowed back into revenue service without being 'certified', a review was undertaken of PR R 90427 Fleet Assurance – Post Incident.
The review resulted in the procedure being updated to ensure trains are certified following incidents and was re-issued.
Sydney Trains did not have effective controls for overspeed where high risk turnouts were present.
Response by Sydney Trains
Since this incident Sydney Trains has undertaken several actions:
Sydney Trains has initiated a project titled: ATP High Risk Turnout Project. The concept phase of this project is under way with the following works currently funded to $5M.
- Signalling and Track Turnout Data collection, collation and verification of all turnouts across the network
PHI International Australia’s operational risk assessment did not capture the risk of the crew’s limited experience on type at night.
Sharp Airlines’ Flight crew operating manual required that:
The Adventure Flight Training school management practices did not provide the required level of supervision, training and assurance that their graduates had achieved the required level of aeronautical knowledge and understanding for the qualifications they received.
The Recreational Aviation Australia pilot theory examination system did not incorporate sufficient risk controls to ensure that their examination processes were followed as intended and their members had achieved the minimum required knowledge in accordance with the syllabus of flight training.
The Civil Aviation Safety Authority (CASA) Sport and Recreation Aviation Branch did not have a process in place to verify if individuals subject to a suspension from a self‑administering organisation held a CASA licence and to ensure the information was provided to the CASA Coordinated Enforcement Process for review.
The New South Wales National Parks and Wildlife Service operating procedures referred to, but did not define, ‘essential personnel’, or specify their roles and responsibilities as task specialists when performing aerial work activities.
The Heli Surveys Safe Work Method Statements for low-level survey and alpine operations did not identify the operational factors that could affect the control of the helicopter. There was also no requirement for its pilots to conduct a pre-flight risk review for low-level survey operations. Combined, this limited the operator’s ability to manage the possibility of loss of tail rotor effectiveness and ensure that the risks associated with low‑level survey operations were as low as reasonably practicable.
The New South Wales Rural Fire Service did not have a procedure to implement a temporary restricted area to reduce the risk of an air proximity event with aircraft not associated with firefighting operations.
The New South Wales Rural Fire Services procedures required an air attack supervisor (AAS) when 3 or more aircraft were deployed to a fireground. However, there was:
The New South Wales Rural Fire Service did not have an effective means to manage wake turbulence separation for aircraft operating in the vicinity of the large air tankers, increasing the risk of an unrecoverable loss of aircraft control.
There was an inconsistent understanding within New South Wales Rural Fire Service state air desk of the threshold required to action task rejection procedures. Consequently, reports of unsafe conditions on the fireground were not promptly actioned.
Neither the New South Wales Rural Fire Service or Queensland Fire and Emergency Service had established cross-border coordination procedures for aerial firefighting activities to ensure reliable aircraft communication and separation.
The New South Wales Rural Fire Service did not have a procedure for ensuring that when large air tankers were dispatched by the state air desk their tasking was coordinated with the incident management team and integrated into the existing incident plan.
The New South Wales Rural Fire Service had no procedure to ensure that fire common traffic advisory frequencies (Fire-CTAFs) were reliably known by state air desk personnel. This resulted in aircraft being dispatched with incomplete Fire-CTAF information.
Neither the New South Wales Rural Fire Service or Queensland Fire and Emergency Service had established cross-border coordination procedures for aerial firefighting activities to ensure reliable aircraft communication and separation.
