ARTC's network rules did not provide suitable guidance to assess continued safe operation when responding to track circuit faults. Additionally, the network rules permitting signals to be passed at Stop did not require a reduction in speed when the condition of the track was unknown.
The Sydney Trains worksite briefing process did not compel a new work group to seek a worksite protection pre-work briefing when accessing an existing worksite.
The worksite protection method presented an increased risk, in that track workers might inadvertently exit the worksite, and subsequently be in the immediate vicinity of operational main line rail traffic. Sydney Trains network rules and procedures for a Track Occupancy Authority did not manage the increased risk for the chosen worksite protection method.
The network rules and procedures require communications to be clear, brief and unambiguous. Network communications by various parties in Sydney Trains were not in accordance with the principles underpinning the network rules.
Sydney Trains’ work-planning process, involving multiple work groups, did not assure the consideration of worksite safety for all tasks undertaken by each involved party over the duration of the work and when returning the rail infrastructure into service.
Pacific National's training course for the loading and securing of freight, and their verification of competency checks for inspection staff, did not include the Freight Loading Manual requirements for non-standard and modified containers.
While the Freight Loading Manual was available to customers, Pacific National did not actively advise them when they had a responsibility identified by the manual. Further, they did not have a process for ensuring that customers complied with the manual’s requirements.
The ship’s manager’s (Yang Ming) cargo-planning process ashore did not ensure that the proposed container stowage plan complied with the stowage and lashing forces requirements of the ship's Cargo Securing Manual. Consequently, compliance with these requirements relied entirely on shipboard checks, made at a late stage, with limited options available for amendments without unduly impacting commercial operations.
The Cicaré 7T/B/BT mandatory service bulletin (BSC007) for the general stabiliser support assembly provided limited guidance for disassembly of the manufactured component and did not stipulate a compliance period within which to perform the inspection nor provide consideration for repeat inspections. This potentially reduced the opportunity to detect the presence of crack initiation and growth in the stabiliser support assembly.
The rostering of the driver in the days leading up to the incident was inconsistent with Sydney Trains' rostering principles.
Sydney Trains' risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances where the presence of an intermediate train stop at Richmond may have reduced the risk of trains approaching the station at excessive speed.
Sydney Trains’ risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when there were deficiencies in the buffer stop design at Richmond and at other locations.
When A42 collided with buffer stop at Richmond station No. 2 platform, the reinforced concrete end stop of the buffer stop withstood the impact of the collision and prevented the train from crossing into a pedestrian and main road precinct. The two hydro-pneumatic rams on the front of the buffer stop did not perform their intended function. They were not aligned with the front of the Waratah train and instead of absorbing energy from the collision, they penetrated the cavity either side of the front-of-train coupler.
The crash energy management system on the Waratah passenger train A42 reduced the impact force of the collision but not all components performed as designed. The performance of the crash energy management system was significantly limited by the buffer stop at Richmond being incompatible with the front of the Waratah train.
The pre-flight safety briefing and safety information card did not include a clear instruction on how to activate the flow of oxygen from the passenger oxygen masks and that the bag may not inflate when oxygen is flowing. This resulted in some passengers not understanding whether or not there was oxygen flowing in the mask.
The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors:
Tugs were to be available to escort the mini cape-size ships until they had entered the South Channel, where they were stood down. However, the tug masters had not been trained in the specifics of escort towage nor in emergency response.
In pre-trial simulations, the risks associated with engine failure during departure were only considered up to when a ship had entered the South Channel. Consequently, the tugs were not in attendance to assist if propulsion was lost.
There were a total of 16 engine malfunction events globally over a 4-year period attributed to modification of the Advantage 70™ engine. The modification increased the engine outer duct gas path temperature, which led to distortion and liberation of the outer transition duct segments.
Response by Pratt and Whitney (P & W)
The fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform the equipment would not have worked correctly, resulting in serious or fatal injuries.
