The ARTC systems for managing track lateral stability did not lead to the location being managed as a location potentially vulnerable to instability.
Response by Australian Rail Track Corporation (ARTC)
Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.
Virgin Australia Airlines did not require ATR flight crews to complete the Before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying was critical.
Pacific National's Freight Loading Manual did not require the use of radial unitising straps to prevent telescoping on jumbo coils where the thickness of the steel was greater than 2 mm.
Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose.
Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of strap breakage due to contact with the cradle.
Pacific National's Freight Loading Manual, specific to the loading and unitising of jumbo coils, did not require the use of rubber load mat on cradles. Consequently, there was no requirement to consider the condition of load mat during inspection and maintenance. This allowed the continued use of cradles without load mat, which decreased their effectiveness at restraining loads.
Neither Alstom’s validation processes nor fault monitoring processes were sufficient to detect the overcharging of batteries prior to the event.
Inspection records for the December 2010 wheelset maintenance activity and wheel change on wheelset number 7E5S 831444 were not available. It is a requirement specified in Pacific National's Wagon Maintenance Manual that records be retained for a period of 12 years.
Axle testing on wheelset number 7E5S 831444 was not carried out during the two most recent wheelset maintenance events in January 2016 and November 2016. It is likely the axle crack existed at the time of these maintenance activities.
Elements of the safety and environment management system are reliant on procedures being followed to manage safety risks. There is little scope for the system to recover when there has been a human error or other procedural error.
The system of placing protection flags on both ends of a train set does not provide a positive isolation of energy to ensure a train cannot be moved while it is being worked on.
The Skitube system for managing access to track did not detect the conflict of the rail maintenance worker under the train at the same time the train was being shunted.
The Robinson R44 pilot’s operating handbook low rotor RPM recovery procedure did not include reference to the minimum power airspeed for the helicopter as a consideration, which may assist a pilot to recover from a low rotor RPM condition. [Safety Issue]
Professional Helicopter Services did not have a calibration schedule for their passenger scales, which were under-reading. This increased the risk of their helicopters not achieving their expected take-off performance.
Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combined roles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation alert or runway incursion alert at their workstation.
The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient to effectively reduce the risk of a runway incursion.
Although Qantas provided detailed guidance to flight crews about the content of departure and approach briefings, it did not specifically require aerodrome hot spots to be briefed.
VicTrack’s contractor, UGL Engineering Limited, did not provide signalling testers with specific instructions detailing the scope of work to be conducted at each stage of a project, but rather, only provided packaged isolation plans for the entire project. The absence of these instructions increased the risk of the works being incorrectly implemented.
The procedures in the aircraft maintenance manual relating to chip detector debris analysis were written in a way that could cause confusion and error. This probably influenced the actions of the maintenance personnel to release the aircraft to service with a deteriorating bearing.
