ARTC procedures for managing limit of authority over-runs by trains appear to be inconsistent with the applicable network rule as they do not mandate an immediate emergency call from the train control centre to the train crew as the first response.
There was insufficient sighting distance of the Down distant signal and insufficient distance between the Down distant signal and Down outer home signal at Gloucester to allow train 2WB3 to stop at the Down outer home signal from the permitted track speed of 70 km/h.
NSW Trains’ methods of providing safety information to passengers (including verbal safety briefings, onboard guides and signage) did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency.
The Australian Transport Safety Bureau recommends that Airbus takes safety action to address the effectiveness of the mitigations to the design limitation associated with the A330 cabin pressure control systems.
NSW Trains’ methods of providing safety information to passengers (including verbal safety briefings, onboard guides and signage) did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency.
Likely due to a training deficiency, Alliance Airlines flight crews' conduct of the Before start procedures and Pre-take-off brief review were not being performed effectively to ensure the speed selector knob was correctly set and checked, which increased the risk of a low-speed event after take-off.
There was insufficient sighting distance of the Down distant signal and insufficient distance between the Down distant signal and Down outer home signal at Gloucester to allow train 2WB3 to stop at the Down outer home signal from the permitted track speed of 70 km/h.
Although Airservices Australia used applied operational risk assessments to high-level threats, it did not formally assess and manage the risk of specific threat scenarios. As a likely result, Airservices did not formally identify and risk manage the threat of separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport, even though it had been a known issue among controllers generally.
The methods used in the Australian Standard AS 1742.7:2016 to calculate safe stopping distances, and determine the need and location of advanced warning signs for road approaches to level crossings, did not account for the likelihood of detecting the level crossing ahead based on the normal visual focal points of road drivers negotiating a curved road. While the standards included guidance for the use of active warning signs for curved road approaches to flashing light controlled crossings, this was not mandatory.
