It was possible that at times throughout the Network Control Officer’s roster, fatigue levels were conducive to performance degradation.
The ARTC form ANRF-002 (Track Occupancy Authority) was deficient as there was no provision to record critical information regarding the location and type of worksite. Consequently, both the Protection Officer and Network Control Officer incorrectly concluded that the train had passed beyond the limits of the worksite.
High service time stage-2 LP turbine blades were susceptible to a reduction in fatigue endurance as a result of vibratory stresses sustained during operation at speeds close to the maximum.
LP turbine support bearings (part numbers LK30313 and UL29651) showed increased susceptibility to breakdown and collapse under vibratory stress conditions associated with LP turbine blade release.
The threaded connections on the Kawasaki air breathing apparatus and oxygen breathing apparatus cylinders were the same and there were no other engineering controls to prevent an oxygen cylinder from being connected to the air compressor.
The ship’s safety management system documentation provided the crew with no guidance in relation to the operation and maintenance of the ship’s oxygen breathing apparatus.
The ship’s crew were not appropriately trained or drilled in the operation and maintenance of the oxygen breathing apparatus.
New Section Closing and Opening Authority Telegrams (SCAO) were not completed by the train controller and the Supervisor (Track Machines) for each closing and opening of the track in accordance with WestNet Rule 199.
The Australian Transport Safety Bureau encourages all operators and owners of R44 helicopters that are fitted with all-aluminium fuel tanks to note the circumstances of this accident as detailed in this preliminary report. It is suggested that those operators and owners actively consider replacing these tanks with bladder-type fuel tanks as detailed in the manufacturer's Service Bulletin (SB) 78A as soon as possible.
The Williamtown air traffic control procedures did not clearly define the separation responsibilities and coordination requirements between the Approach sectors for departing aircraft.
An important alerting function within the Australian Defence Air Traffic System had been disabled at Williamtown to prevent nuisance alerts.
The Department of Defence’s air traffic controllers had not received training in compromised separation recovery techniques.
The aircraft operator’s flight crews were probably not adequately equipped to manage the vertical profile of non-precision approaches in other than autopilot managed mode.
The operators recurrent simulator training did not address the recovery from a stall or stick shaker activation such that the ongoing competency of their flight crew was not assured.
The operator's procedure for confirming the validity of the flight management system generated take-off weight did not place sufficient emphasis on the check against the load sheet.
The presentation on the aircraft load sheet of the zero fuel weight immediately below the operating weight, increased the risk of selecting the inapropriate figure for flight management system data entry.
The operators procedures did not include a validation check of the landing weight generated by the flight management system which resulted in lack of assurance that the approach and landing speeds were valid.
The current ARTC definition of restricted speed requires considerable judgement on the part of train drivers.
Double stacked container wagons are at particular risk of wind induced roll-over. This is a direct relationship of exposed side area, and was therefore probably exacerbated by out of gauge/high loads on some wagons with a large surface area exposed to the gust front.
Train drivers receive no formal training with respect to understanding severe weather events, the associated derailment risk and mitigation strategies.
