At the time of the collision, the Australian Rail Track Corporation and the Port Adelaide Enfield Council did not have an interface coordination plan to manage the risks associated with the Stirling Street level crossing interface, including the installation and maintenance of pavement marking.
Regulatory guidance regarding the measurement of fuel quantity before flight lacked clarity and appropriate emphasis and did not ensure that the fuel quantity measurement procedures used by operators included two totally independent methods.
There was no regulatory requirement for simulator training in Australia.
Response from CASA: 31/08/2009
CASA will address this issue and will commence a review of the legislation. In the course of that review, CASA will consider whether there is a need to mandate the use of simulators in connection with certain flight crew training requirements in the air transport sector, and other sectors where this may be appropriate.
The practices used by the operator’s pilots for measuring and logging of fuel quantity were inconsistent.
The absence of simulator training meant that the endorsement and other training the flight crew had undergone did not adequately prepare them for the event.
There was no record to indicate that a worn section of rail, inserted into the track on 25 July 2007, was tested as being suitable for reuse as prescribed in the WestNet Rail Standard Gauge Mainline Code of Practice. The lack of construction and maintenance documentation compromises the ability to maintain railway infrastructure safely and places greater importance on adhering to mandated test procedures.
