The manufacturer’s classification, relating to the criticality of failure, of the HP/IP bearing support assembly was inappropriate for the effects of a fire within the buffer space and hence, the requirement for an appropriate level of process control was not communicated to the manufacturing staff.
The coordinate measuring machine was programmed to measure the location of the oil feed stub pipe interference bore with respect to the manufacturing datum, instead of the design definition datum as specified on both the design and manufacturing stage drawings.
The engine manufacturer's process for retrospective concessions did not specify when in the process the Chief Engineer and Business Quality Director approvals were to be obtained. Having them as the final approval in the process resulted in an increased probability that the fleet-wide risk assessment would not occur.
The engine manufacturer’s group quality procedures did not provide any guidance on how manufacturing personnel were to determine the significance of a non-conformance, from a quality assurance perspective.
The stevedoring company had not identified stevedore fatigue as a risk to the company or its operations and, as a result, had not implemented a system to manage fatigue. Consequently, its operations were exposed to a level of fatigue-related risk that had not been assessed and treated.
While the risk of aluminium ingot stacks toppling over had been identified by the stevedoring company as a result of past incidents, its procedure for loading aluminium products had not evolved to adequately address this risk. Furthermore, the implementation of basic precautions such as using ladders to climb between ingot tiers was not effectively monitored or enforced.
The aluminium ingot lifts in Newcastle, comprising multiple stacks of ingot packs strapped together, with an effective height to width ratio of 5:1 were inherently unstable. Furthermore, handling and stowage of ingot lifts involved the risk of a lift being disturbed and one or more of its packs falling or toppling because the lifting and other straps were not designed to restrain the packs as a single homogenous cargo unit and were prone to failure.
A risk assessment for mooring a ship at the inner moorings had never been undertaken. As a result, the risks associated with leaving a ship at the inner moorings overnight during the swell season were not properly identified and strategies to minimise those risks were not implemented.
While the pilot provided limited advice to masters of ships visiting Christmas Island, the port operator did not provide the master of ships intending to berth using the buoys in Flying Fish Cove with any written or verbal guidance regarding berthing and unberthing arrangements and emergency contingencies.
The port operator was aware that the type of locking pin arrangement on the cantilever line joining shackle was not effective in preventing the shackle’s pin from working its way free. However, the operator had not implemented a program of replacing the shackles in the entire mooring system in Flying Fish Cove with new shackles that had a more robust locking pin arrangement.
The port operator had not implemented an effective planned inspection and maintenance program for the mooring system in Flying Fish Cove. Consequently, it had been 18 months since the underwater components of the cantilever line had been inspected.
The helicopter’s lighting set-up did not allow independent control of the searchlights by the pilot using the switches on the flight controls, as required by the operations manual and Civil Aviation Order 29.11, and increased the risk of loss of hover reference and distraction in the case of a single light failure or switch mis‑selection by a pilot.
The increased capability of helicopters and rescue winches enabled the conduct of complex winch rescues beyond the current level of winch training and procedural support associated with the traditional special casualty access team clinical access role, leading to an increased risk that hazards associated with complex rescues were not identified.
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.
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.
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.
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.
