Seven Seas Voyager’s planned maintenance system (PMS) contained no information about waste incinerator ash grate replacement, a task that would have been periodically undertaken by different engineering staff since 2003. Therefore, in this respect, the shipboard procedures that documented requirements for the PMS had not been effectively implemented.
The ARTC’s inspection and maintenance practices were ineffective at identifying and correcting the deteriorating condition of track infrastructure exhibiting accelerated wear, such as 38A points at Spencer Junction.
A caution order instrument was used that lacked a specific requirement for train crews to check the points along their route. This requirement becomes critical under circumstances of signalling system degradation.
The Train Control System permitted the NCO to set an unviable route for the train and then displayed it as viable. The train control system alarm designed to alert the NCO to the setting of an unviable route was nullified by the absence of gauge detection.
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.
The ship’s managers did not have effective systems to ensure that the defective control system for the controllable pitch propeller was reported to the relevant organisations as required.
Consequently, Brisbane’s vessel traffic services, pilotage provider and the pilot remained unaware of the defect and could not consider it in their risk assessments before the pilotage started.
The ship’s agent’s information questionnaire did not ask for all of the information required to complete the QSHIPS booking form and ensure that defects were reported.
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.
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.
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 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.
