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 Department of Defence’s air traffic controllers had not received training in compromised separation recovery techniques.
An important alerting function within the Australian Defence Air Traffic System had been disabled at Williamtown to prevent nuisance alerts.
The Williamtown air traffic control procedures did not clearly define the separation responsibilities and coordination requirements between the Approach sectors for departing aircraft.
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 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 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 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.
The available Cross Crew Qualification and Mixed Fleet Flying guidance did not address how flight crew might form an expectation, or conduct a ‘reasonableness' check, of the speed/weight relationship for their aircraft during takeoff.
The implementation of Patrick Terminal’s safety management system resulted in an environment where Patrick Terminal management and stevedores were disconnected in relation to the management of some of the day-to-day workplace safety risks. As a result, there was little ownership of the safe work instructions by the stevedores, and some of the more experienced stevedores were probably no longer aware of the risks posed to them when they undertook unsafe ‘workarounds’ in the workplace and these were not identified by Patrick management.
Industry practices for tracking faults or performance problems with line-replaceable units are limited, unless the units are removed for examination. Consequently, the manufacturers of aircraft equipment have incomplete information for identifying patterns or trends that can be used to improve the safety, availability or reliability of the units.
There was a limitation in the algorithm used by the A330/A340 flight control primary computers (FCPCs) for processing angle of attack (AOA) data. This limitation meant that, in a very specific situation, multiple spikes in AOA from only one of the three ADIRUs could result in a nose-down elevator command.
