HC Rubina’s electronic planned maintenance system did not contain any instructions to ensure that the shaft alternator flexible coupling was maintained in accordance with the manufacturer’s requirements.
All-engine go-arounds in modern air transport aircraft are often a challenging task when there is a requirement to level-off at a low altitude, and many pilots have had limited preparation for this task.
The procedures for locomotive inspection and maintenance were not effective at identifying and addressing continuing fuel leakage problems on this type of fuel filter assembly.
The company’s Required Navigation Performance approach procedure allowed the flight crew to set the approach minimum altitude in the auto-flight system prior to commencing the approach. This did not ensure the altitude alerting system reflected the assigned altitude limit of 7,000 ft and removed the defence of that alert when the flight crew did not identify the disengagement of the flight management computer-derived VNAV PTH mode.
When the crossing was last surveyed under the ALCAM program, the measurement of the road angle resulted in an overestimation of the acute road-to-rail interface angle. The implication of overestimating the acute interface angle is that sighting deficiencies may be underestimated or not identified.
For eastbound road users approaching the B. McCann Road level crossing along the left-side of the road, the view to the track was restricted due to the acute road-to-rail interface. This was particularly problematic for trucks with the viewing opportunity to the left limited to the cab’s passenger-side window.
The road incline on the west-side approach to the crossing increased the time required for loaded trucks to transit the crossing.
There existed an inconsistency between the track speed used for crossing assessment and permitted train speeds. The ALCAM process used a train speed equal to the track line speed, whereas V/Line systems for evaluating driver behaviour permitted an exceedence of line speed by up to 10 km/h for short distances.
V/Line did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the rail operator in 2009.
The give-way protection installed at the crossing was inconsistent with the available sighting distances on both approaches to the crossing. Sighting was affected by vegetation, embankments formed by a rail cutting and the curved road approaches.
The level crossing safety coordination processes did not involve a key stakeholder, the gypsum mine owner, who had knowledge of the changing traffic profile. The mine owner was aware of the increasing numbers of heavy vehicles using B. McCann Road since 2010 and the associated changing risk profile of the level crossing.
Gannawarra Shire did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the Shire in 2009.
The Darwin Approach long-range display was a low resolution screen that presented air traffic control system information with reduced clarity and resulted in it having diminished effectiveness as a situation awareness tool.
The Department of Defence had not provided Darwin-based controllers with regular practical refresher training in identifying and responding to compromised separation scenarios.
The Department of Defence’s risk assessment and review processes for the implementation of the Comsoft Aeronautical Data Access System and removal of the flight data position did not effectively identify or manage the risks associated with the resulting increased workload in the Darwin Approach environment, in particular with regard to the Planner position.
Darwin Approach controllers were routinely exposed to green (limited data block) radar returns that were generally inconsequential in that Approach control environment, leading to a high level of expectancy that such tracks were not relevant for aircraft separation purposes. Refresher training did not emphasise the importance of scanning the green radar returns.
The Australian Defence Air Traffic System (ADATS) did not automatically process all system messages generated by The Australian Advanced Air Traffic System. In cases where transponder code changes were not automatically processed, the risk controls in place were not able to effectively ensure that the changes were identified and manually processed.
The proximity of the landing gear selector valve electrical wiring loom to the external hydraulic power connectors within the left engine nacelle on Fairchild SA227-AT Metro aircraft resulted in the ‘down selection’ wire being damaged during routine maintenance activities.
Bosphorus’ safety management system provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage.
Brisbane Marine Pilots’ ‘Port of Brisbane Passage Plan’ did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
