STM did not require the application of all available and reasonably practicable risk controls when parking trams with respect to their location and handbrake application.
STM did not comply with its risk control in ensuring that trams were attended when parked.
STM did not follow its change management process for adopting the new hardwood chock type. Subsequently, the hardwood chock could not be applied reliably under the ‘J’ class wheel and could not restrict its movement.
The En Route Supplement Australia (ERSA) did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.
Virgin Australia did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.
The absence of centreline lighting and the 60 m width of runway 11/29 at Darwin result in very limited visual cues for maintaining runway alignment during night landings in reduced visibility.
Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions. The installation of centreline lighting on wider category I runways is recommended but not mandated by the International Civil Aviation Organization Annex 14.
A NAV ADR DISAGREE alert can be triggered by either an airspeed discrepancy, or angle of attack discrepancy. The alert does not indicate which, and the associated procedure may lead flight crews to incorrectly diagnosing the source of the alert when the airspeed is erroneous for a short period and no airspeed discrepancy is present when the procedure is carried out.
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.
