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 procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.
SPAD Investigation Form (RS-ADL-283) used by Public Transport Services does not collect data on many of the human factor issues that would facilitate a better understanding of why SPADs are occurring.
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 aircraft maintenance manuals did not include the operating specifications of the replacement cabin altitude warning pressure switch hampering the required verification of switch serviceabilty.
The cabin altitude warning pressure switch maintenance manual wiring diagram did not provide a clear indication of the wiring connections for the superseded switch.
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.
The crew did not use resource management principles to ensure that they had a shared mental model of the task that they were carrying out. As a result there was confusion amongst the various crew members as to their roles and responsibilities at the time of the incident
The training provided to the crew did not ensure they were familiar with the function or operation of the wave compensator or its safety interlock
It was found that the safety interlocks on the wave compensator systems on board British Sapphire, British Emerald and British Ruby had been electrically by-passed thereby preventing the safety interlocks from functioning.. As a result, the wave compensators on board all three ships could be engaged regardless of whether the fast rescue boats were waterborne or suspended from the fall wire
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
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
The planned maintenance system on board British Sapphire did not detail a procedure for a recommissioning test following maintenance on the fast rescue boat davit. As a result, any recommissioning test that was done after on board maintenance had not identified the issue with the wave compensator safety interlock prior to the incident.
British Sapphire’s fast rescue boat davit procedures did not provide sufficient guidance for the crew in the operation of the wave compensator
