Newlead Bulkers had not implemented any procedures or guidance to inform the crew that extra vigilance was required when operating the main engine in engine room control mode because there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’.
Paint application to the main rotor gearbox, gear carrier did not effectively protect the part from corrosion resulting from gearbox water ingress.
Differences in the traffic alert phraseology between the Manual of Air Traffic Services and Aeronautical Information Publication increased the risk of non-standard advice being provided by the controller to the pilot of the G-IV during the compromised separation recovery.
There has not been a comprehensive risk based approach to contingency planning for deep draught bulk carrier operations in Gladstone.
There has not been a comprehensive safety management system implemented in the Port of Gladstone with the aim of identifying, evaluating and controlling pilotage related risk.
The shipyard commissioning processes did not identify that the ship’s rudder angle indicator transmitter and tiller link-arm were not installed correctly.
The quality assurance processes used in the acceptance of the Goddards crossing loop project were not sufficiently robust to mitigate the risk of track construction inadequacies.
The aircraft's centre of gravity varied significantly with hopper weight and could exceed both the forward and aft limits at different times during a flight.
The Auto Release procedures at Melbourne Airport allowed for aircraft to be departed at or close to the separation minima, with no controls in place to ensure aircraft would maintain a minimum speed and flight crews would advise air traffic control if the speed could not be achieved.
A number of self-locking nuts from other aircraft, of the same specification as that used to secure safety-critical fasteners in VH-HFH, were identified to have cracked due to hydrogen embrittlement.
A significant number of R44 helicopters, including VH-HFH, were not fitted with bladder-type fuel tanks and the other modifications detailed in the manufacturer's service bulletin 78 that were designed to provide improved resistance to post-impact fuel leaks.
Some ARTC maintenance contractors were using non-authorised reproductions of the ARTC’s Track Occupancy Authority form.
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.
It was possible that at times throughout the Network Control Officer’s roster, fatigue levels were conducive to performance degradation.
The track workers were not provided with sufficient training (competency based or structured on-job training) in relation to the hazards and required protections for working under the authority in place at Newbridge on 5 May 2010.
The ARTC procedure ANPR-701 (Using a Track Occupancy Authority) was inconsistent in that it did not allow for a scenario that would otherwise be permitted, and intended, under rule ANWT-304 (Track Occupancy Authority).
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.
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.
