Bosphorus’ safety management system did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
Sydney Trains validation processes were not effective in detecting errors in Special Train Notice (STN) 1004 prior to the Local Possession Authority (LPA) implementation.
There were non-compliances to the repeat back provision because it was viewed as onerous under certain Local Possession Authorities (LPAs). An opportunity exists to review rule non-conformance with the implementation of LPAs.
Transfield did not have adequate systems in place to ensure workers were not adversely affected by drugs or alcohol while conducting safety related work in a remote work environment.
Transfield did not provide oversight sufficient to identify and rectify the non-compliant work practices in the road-rail vehicle operation involved in this occurrence.
The absence of a national standard that addresses the design, fitment and maintenance of rail guidance equipment and the safety performance for road-rail vehicles while on-rail, increases the risks associated with operating road-rail vehicles.
Transfield’s training regime did not ensure that the track workers involved in this occurrence were trained in new or updated work practices relating to road-rail vehicle operations. Similarly, relevant amended procedures, safety bulletins and alerts had not been effectively promulgated to these employees.
The maintenance regime for Hino TS63 was inadequate and did not account for the accelerated wear and tear on the vehicle when used as a road-rail vehicle.
The procedures and guidance documentation for authorising movement past signals displaying a Stop indication was ambiguous.
The process undertaken by the network control officer for issuing a Caution Order does not require validation of compatibility between the train gauge and the established route.
The train operator’s Route Knowledge Package did not include track layout diagrams, or specific information warning of the existence of dual-gauge turnouts where track terminated in one direction.
When train 9501 approached signal DYN114, which was displaying a Stop indication, there was minimal indication to the network control officer that the train gauge and the selected route were incompatible.
The configuration of the dual-gauge points assembly led to a truncated broad-gauge rail in one of the turnout directions.
There was no warning indication at signal DYN114 to warn train crews that the broad-gauge rail terminated in the straight-ahead direction.
The train control system screen display provided no direct indication to the network control officer that one section of the established route was dual-gauge and another section single-gauge.
Although the operator’s rostering practices were consistent with the existing regulatory requirements, it had limited processes in place to proactively manage its flight crew rosters and ensure that fatigue risk due to restricted sleep was effectively minimised.
Jabiru engines manufactured before July 2011 have reduced strength and reliability of the crankshaft/propeller flange joint, compared with the later design that incorporated positive location dowel pins.
The manufacturer’s specified procedure for assembling and torqueing of the crankshaft/propeller flange fasteners was ineffective in ensuring resistance against subsequent joint movement in service.
The engine manufacturer’s documents with respect to the propeller mounting flange were technically inconsistent with regard to painting and torqueing procedures.
Track walking inspections were not conducted at intervals specified by V/Line’s maintenance program
