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.
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.
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.
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 Lloyd’s Register takes steps to approach the International Association of Classification Societies and seek safety action to address the risk associated with a single point of failure in electrical power supply for ship's rudder angle indicators.
The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions.
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 NSW Trains undertake further work to improve the methods used to provide safety information to ensure that passengers are given a reasonable opportunity to gain knowledge of what they may be required to do in the event of 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.
The ATSB recommends that Eastern Air Link address the safety issue, through provision of guidance and training to flight crew concerning the safest option in the selection of an approach method when weather conditions are marginal for the conduct of a visual approach.
