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.
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 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.
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 axle bearing installation process was not sufficient to ensure the tabs on the locking plate were installed correctly.
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.
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.
CASA did not seek information to establish whether there was ‘evidence of risk to third parties on land, sea or air’ prior to issuing the Special Certificate of Airworthiness.
