Before the incident, Orica Australia had advised the Australian Maritime Safety Authority (AMSA) that their packaging method for the prills was fully compliant with the IMDG Code’s provisions. However, AMSA’s IMDG Code compliance audit regime had not detected that the method was not compliant.
At the time of the incident, there was no requirement for any third party to inspect or survey the fixed and loose lashing equipment on a ship. Had this been done, the maintenance and replacement regime of such equipment on board Pacific Adventurer might have been more effective.
The poor condition of much of the ship’s container lashing equipment indicates that the inspection and maintenance regime applied to this critical equipment had been inadequate.
When revising or maintaining its A320 endorsement training program, the third party training provider did not use or have access to current versions of the aircraft manufacturer’s recommended training program.
By the time of the 28 October 2009 occurrence, many of the operator’s A330 flight crew had not received unreliable airspeed training. Such training started being introduced in the operator’s recurrent training program before the occurrence.
The ammonium nitrate prills were not packaged in the containers in accordance with the requirements of the IMDG Code. The containers were packed in a way which allowed the prills to move within the container in a way that may have contributed to the failure of the containers and/or the lashing system.
River Embley’s planned maintenance system did not require routine testing of the compressor high temperature alarm/shutdown.
The manufacturer’s maintenance manual did not include a requirement for the routine testing of the compressor high temperature alarm/shutdown.
The ARTC does not have a check list available for network controllers to assist in identifying risks associated with the verbal authorisation of train movements for an integrated yard.
There was no formal risk assessment process in use at the operator’s Horn Island base.
At the time of the last tyre change, crack initiation at the bearing bore shoulder radius was an emerging issue with no requirement for mandatory inspection of this area during a tyre change.
The post-2005 main landing gear wheel design had shown a susceptibility to fatigue cracking at the inner hub bearing bore shoulder radius.
The operator’s winching procedure did not include the requirement to confirm adequate hover reference existed overhead an intended winch area prior to deploying personnel on the winch.
As the re-signalling of Cootamundra neared completion it became necessary to undertake control table and software development concurrently to meet the targeted commissioning date. Normally control table and software development is done sequentially to ensure that all the control table logic is fully reflected in the final software and associated validation/testing processes.
Where a design involves complex signalling arrangements, it may be beneficial to involve the designing engineer during the final onsite field testing phase as they have the best understanding of the interlocking principles. This places them in a strong position to identify any design omissions or deficiencies that may not have been evident during earlier phases of a project.
Where a signalling design has implicit safety requirements that need to be validated onsite, field testers should be provided with comprehensive check notes and/or clearly annotated information that ensures specific testing requirements are not omitted.
The South Improvement Alliance engineers did not effectively identify and record that the interface between CA74C and CA74D was the fouling point between the Up Main line and No.1 Platform Road and thus did not recognise that the rear of a train sitting on the Up Main line at this location would foul No.1 Platform Road. The design deficiency was caused by a long standing practice of not explicitly recording the clearance point on the Signal Arrangement Plan, Track Insulation Plan or in the Control Tables.
The documentation and quality control processes used by the South Improvement Alliance for the Cootamundra re-signalling project were not sufficiently robust, in particular, the closing out of identified design issues was inadequate.
Although the Australian Rail Track Corporation was not resourced to actively participate in the design or commissioning phases of the Cootamundra re-signalling project, greater involvement by the Australian Rail Track Corporation (local knowledge of site geography and layout) during these phases may have assisted the South Improvement Alliance engineers in detecting the design error.
