The design of the horizontal stabiliser bungs did not consider aspects that would ensure the identification of an installed bung, or the safe operation of the aircraft if the bungs were not removed prior to flight.
There were no formal procedures for the storage and accountability of horizontal stabiliser bungs after they were removed from the aircraft.
Airservices Australia’s compromised separation recovery training for Sydney tower controllers did not include scenarios involving aircraft below the minimum vector altitude at night.
Airservices Australia did not have procedural controls to separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport while below the minimum vector altitude at night.
Although Airservices Australia applied operational risk assessments to high-level threats, it did not formally assess and manage the risk of specific threat scenarios. As a likely result, Airservices did not formally identify and risk manage the threat of separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport, even though it had been a known issue among controllers generally.
The Airservices Australia MARUB SIX standard instrument departure and the missed approach procedure for runway 34R directed aircraft onto outbound tracks that did not sufficiently assure separation between aircraft following the procedures concurrently.
NSW Trains’ training of passenger services crew did not include periodic simulated exercises that would allow crew members to demonstrate and maintain the knowledge and skills required in an emergency.
NSW Trains’ procedures did not provide specific instructions to passenger services crew on when, how and what to communicate to passengers in an emergency.
NSW Trains’ methods of providing safety information to passengers (including verbal safety briefings, onboard guides and signage) did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency.
Contemporary Australian industry rail standards did not include requirements for ground-level access to or egress from driver's cabs in the event of a rollover.
Contemporary Australian industry rail standards did not include structural requirements for cab doors, or other performance-based requirements, that addressed the protection of train crew in the case of vehicle overturn.
NSW Trains did not have a functioning system to monitor that drivers starting their shift at Junee received and had understood distributed safety information.
NSW Trains did not have a functioning process for obtaining safety information from the ARTC web portal for its rolling stock operations within Victoria and did not routinely obtain ARTC train notices.
ARTC distribution of safety information by train notice was sub-optimal. There was scope to improve reliability of safety information distribution and to consider opportunities for operators in Victoria (and SA and WA) to receive direct distribution of train notices for their operations on the ARTC network.
For the establishment of train working arrangements that deviated from ARTC network rules, ActivateRail did not implement processes to ensure its contributions were consistent with the risk management procedures of the accredited rail infrastructure manager (ARTC) and Australian risk management standards.
For the establishment of train working arrangements that deviated from ARTC network rules, ARTC stakeholder engagement did not support its management of the safety risks to network users and the development of agreed risk controls.
For the establishment of train working arrangements that deviated from ARTC network rules, ARTC risk management and oversight processes resulted in a risk management plan that was limited in context, scope and risk identification and risk controls that had significant weaknesses.
For the routing of trains through Wallan Loop on 20 February, ARTC processes did not result in its effective engagement with network users that would be affected by this change.
