Although the NAV ADR DISAGREE had more immediate safety implications relating to unreliable airspeed, the ECAM alert priority logic placed this alert below the engine-related faults. As a result, the NAV ADR DISAGREE alert was not immediately visible to the flight crew due to the limited space available on the ECAM display.
The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude (specifically above flight level 200).
The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle.
A more stringent maintenance response than that for an isolated track geometry defect was not considered or implemented in accordance with ARTC’s COP. A more stringent maintenance response should have been considered given the degraded formation and the track’s rapid deterioration between 12-14 January 2016, two days prior to the derailment
The shear key was not installed in accordance with the geotechnical engineer’s specification with respect to the following:
a) It did not include a cross-drain.
b) Its width was less than the specified width.
The location did not have adequate surface drainage which likely contributed to formation degradation over time.
ARTC allowed identified track twist defects to remain in track contrary to network track geometry requirements.
Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements.
Guidelines for the provision, care and use of shipboard equipment were not supported by suitable documentation. The only documentation was for mobile scaffolding equipment of different design and not for that in use on the ship.
The regional harbour master and the pilotage service did not have processes in place to follow up audit findings, to ensure that they were appropriately monitored, actioned and closed out in a timely manner.
The Port Procedures manual for Townsville allowed shipping agents to request a tug reduction without the knowledge of the ship’s master.
The Port of Townsville Limited Pilotage Services’ Pilotage Service Safety Management System did not have documented guidance on berthing manoeuvres nor any associated contingencies.
The Port of Townsville Limited Pilotage Service risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks during pilotage.
Given the parallel runway configuration, there was a disproportionate rate of reported wake turbulence occurrences for aircraft arriving at Sydney Airport compared to other major Australian airports in the years 2012 to 2016. Wake turbulence occurrences at Sydney Airport were found to be primarily associated with three factors:
The train was loaded by approximately 10 per cent more than that recorded on the consist, it is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train.
Although CHC Helicopter Australia’s operations manual stated that emergency medical service flights should be conducted under instrument flight rules (IFR) ‘where practical’, its procedures for night visual flight rules (NVFR) operations using night vision goggles did not clearly state when IFR rather than NVFR should be used.
Although the operator had procedures for conducting a verbal safety briefing prior to flight and had safety briefing cards available, its risk controls did not provide assurance that all passengers would understand the required procedures for emergency landings. More specifically:
The Bureau of Meteorology did not have a procedure to ensure that a recording of the local weather forecast for balloon operations in the Melbourne area was correctly uploaded and accessible to balloon pilots.
The general condition of the rail on the west track, in the vicinity of the rail fracture, contributed to relatively frequent failures in that area.
The engine manufacturer did not have specific inspection procedures in the maintenance documents of the propeller shaft to detect a fatigue crack originating from the dowel pin hole.
