Ambulance rescue crewmen did not conduct any night winching recency training, resulting in an increased risk of unfamiliarity with night winching procedures and their associated hazards.
The accepted use of procedural adaptation by special casualty access team paramedics, and the past success of rescues that involved adapted techniques, probably led to the retrieval procedure that was used on the night.
A significant number of R44 helicopters, including VH-COK, were not fitted with bladder-type fuel tanks and the other modifications detailed in the manufacturer's Service Bulletin, SB-78 to improve resistance to post?impact fuel leaks and fire.
The method used to ultrasonically test the tail pins in-situ was not reliable and resulted in small fatigue cracks going undetected.
RailCorp’s acceptance testing regime for tail pins did not identify that the tail pins stamped BU 06 04 were below standard and, hence, not suitable for service.
There were some minor non-conformances with the level crossing signage, in particular the ‘Stop’ sign assembly and positioning of the ‘Stop’ line on the western side of the Port Flinders Causeway Road level crossing.
Aircraft operations with an enlarged hopper but no associated recalibration of the hopper level sight gauge increased the potential for operations at an uncertain aircraft operating weight, and therefore risk of operations in excess of the published aircraft limitations.
There was limited assurance that M18 and M18A Dromader aircraft incorporating Supplemental Type Certificate SVA521 would exhibit acceptable handling and performance characteristics if not fitted with vortex generators and M18B standard elevators, in particular that the risk of longitudinal instability had been reliably addressed.
There was a potential, depending on the supplements that were incorporated in an aircraft’s flight manual, for pilots and/or operators to apply incorrect operational limitations to agricultural operations in M18 and M18A Dromader aircraft at weights between 4,200 kg and 5,300 kg. This increased the risk of their inconsistent application to these operations, and the likelihood of the unknowing erosion of engineering safety margins and aircraft life.
M18 Dromader aircraft were being operated in the agricultural role at weights for which a 15° bank angle limitation had effect, whereas the nature of agricultural operations increased the risk of pilots exceeding that limitation.
Worker competency procedures were deficient in providing a structured program for the development of route knowledge by the driver-in-training.
There were no formalised processes for a driver-in-training to record their experience in learning a route, or to document feedback related to their performance, which could be used by supervising drivers or assessors to assist in mentoring them.
Specialised Bulk Rail’s Safety Management System procedures did not provide the supervising drivers with sufficient direction as to the nature of their supervisory role.
SBR’s process for assessing its drivers’ roster for relay operations relied excessively on a score produced by a bio-mathematical model, and it had limited mechanisms in place to ensure drivers received an adequate quantity and quality of sleep during relay operations.
Accidents involving Robinson R44 helicopters without bladder-type tanks fitted result in a significantly higher proportion of post-impact fires than for other similar helicopter types. In addition, the existing Australian regulatory arrangements were not sufficient to ensure all R44 operators and owners complied with the manufacturer's Service Bulletin SB-78B and fitted these tanks to improve resistance to post-impact fuel leaks.
The rules and procedures governing the issue of a Controlled Signal Block did not require or provide for coordination between network control officers when the Controlled Signal Block affects more than one controller’s area of responsibility.
The lack of any record of incident reporting by Bowen Tug and Barge, and its employees, indicates an ineffective reporting culture within the company. Hence, the opportunity to learn from previous incidents was lost.
Bowen Tug and Barge’s safety management system guidance for barge storing operations did not designate roles or responsibilities to specific individuals and a system for communicating with the ship’s crew was not discussed and established.
Bowen Tug and Barge had identified the need to spread the slings when lifting a stores container. However, there was no process in place to ensure that ships' crews were advised of this to ensure its safe return from the ship.
Compliance auditing on board British Beech had not identified that requirements of the job hazard analysis were not being followed by the crew during the storing operations.
