There are inconsistencies between Right of Way Work Instructions and the Common General Operating Rules.
Public Transport Services procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.
Public Transport Services driver training does not adequately address the risk of distraction and areas of human performance error with respect to SPAD events.
Public Transport Services do not have a formal fatigue policy/procedure.
Windshields manufactured with terminal block fittings containing polysulfide sealant (PR1829) have been shown to be predisposed to premature overheating failure that could lead to the development of a localised fire.
An examination of wheel impact (WILD) data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, running a trend analysis of WILD data clearly showed that there was a growing wheel impact problem.
Examination of RailBAM® data established that under PN’s existing maintenance guidelines there was no requirement to take wagon RQJW 22034D out of service. However, inspection of the data showed that there was a growing/trending problem with the 2L axle-box.
The cabin altitude warning pressure switch maintenance manual wiring diagram did not provide a clear indication of the wiring connections for the superseded switch.
The aircraft maintenance manuals did not include the operating specifications of the replacement cabin altitude warning pressure switch hampering the required verification of switch serviceabilty.
There were only subtle cues to the fitment of programming dongles and no requirement to test Emergency Locator Transmitter (ELT) programming after installation, increasing the risk of inadvertent and undetected ELT re-programming and a less effective search and rescue response.
Prior to 2 February 2011, the crew had encountered problems with the lifting wire jamming in the head of the davit when the bucket was hoisted too high. However, nothing had been done to prevent it from happening again in the future.
Davit International’s fast rescue boat davit manual did not provide sufficient guidance for the crew in the operation of the wave compensator and its safety interlock
The job hazard analysis for the operation of the fast rescue boat was incomplete and did not include an assessment of the hazards associated with the operation of the wave compensator
Training institutions delivering approved STCW courses are not keeping up to date with the introduction of wave compensation units to ensure their courses provide students with the required knowledge to safely operate these units
British Sapphire’s fast rescue boat davit procedures did not provide sufficient guidance for the crew in the operation of the wave compensator
The planned maintenance system on board British Sapphire did not include a specific requirement to maintain or test the wave compensator or its safety interlock on the fast rescue boat davit. As a result, the crew had not identified the issue with the wave compensator safety interlock during periodic maintenance.
There was no evidence to indicate that the operation of British Sapphire's (or its sister ships) fast rescue boat davit’s wave compensator and safety interlock had been sufficiently tested at the time of the ship's delivery to ensure safe operation
