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.
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.
Worker competency procedures were deficient in providing a structured program for the development of route knowledge by the driver-in-training.
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.
Bowen Tug and Barge did not have an effective compliance auditing process in place to ensure that its employees were following the training they had received and the guidance contained in the safety management system documentation.
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.
There was no requirement for a systematic risk assessment to be conducted and documented when the planned amount of training for a controller was reduced.
A significant number of DHC-8-100, -200 and -300 series aircraft did not have a means of preventing inadvertent or intentional movement of power levers below the flight idle gate in flight, or a means to prevent such movement resulting in a loss of propeller speed control.
Many DHC-8 pilots were not made aware of the sound of the beta warning horn during their training.
The first 39 manufactured DHC-8-100 aircraft had a design problem such that, if the friction control was wound to the full out (friction off) position, the flight idle gate was ineffective in reducing the likelihood of pilots inadvertently moving the power levers below flight idle in flight.
Adonis’s safety management system did not contain any procedure or guidance in regard to the use and correct setting of the tug’s towing hook quick release arrangements.
The location of the towing hook ‘locking’ pin on the upper part of the quick release lever meant that if the pin was not properly in its ‘unlocked’ slot, it could fall into the locking hole, thereby locking the release lever.
The requirement in Sea Swift’s Marine Execution Plan to let Adonis go after clearing the Clinton coal wharves was ambiguous and this led to the crews of Adonis and Wolli misinterpreting the requirement.
MSC Siena’s safety management system procedure for working over the side required that a risk assessment be carried out, and necessary checks and precautions documented in a work permit. However, the procedure had not been effectively implemented on board the ship.
MSC Siena’s permit to work over the side and the associated procedure required that the ship not be underway when working over the side. However, this requirement could not be complied with when working over the side to rig a combination pilot ladder.
