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Responses to safety issues identified in 2020-21

The tables below document each safety issue identified in 2020–21 and its current status assigned by the ATSB, along with the justification for that status.

Aviation

Table 6: Aviation – Responses to other safety issues identified in 2020–21

Safety issue

Status

Status justification

AO-2016-155 Engine failure and forced landing involving Cessna 208B, VH-LNH, 8 km north-west of Solomon Airport, WA, on 16 November 2016

AO-2016-155-SI-01: Pratt & Whitney Canada (PWC) PT6A-114A engines fitted with compressor turbine vane rings that have been repaired in accordance with the United States Federal Aviation Administration‑approved scheme STI 72-50-254 have a significantly increased likelihood of CMSX-6 compressor turbine blade fracture and subsequent failure of the engine compared to those engines fitted with PWC‑manufactured compressor turbine vane rings.

Safety action still pending

Safety issue

Status

Status justification

AO-2017-078 Loss of cyclic control and in-flight break-up involving Robinson R22 helicopter, VH-HGU, 7 km north-north-west of Cloncurry Airport, Qld, on 2 August 2017

AO-2017-078-SI-01: Cloncurry Air Maintenance had adopted a number of practices, which included using abbreviated inspection checklists, not recording all flight control disturbances and not progressively certifying for every inspection item as the work was completed, which increased the risk of memory-related errors and the omission of tasks.

Adequately addressed

The ATSB is satisfied that improvements in Cloncurry Air Maintenance’s use of the job sheets to track the progress of maintenance should reduce their reliance on human memory for the condition of helicopters under maintenance and therefore reduce the risk of memory-related errors.

Safety issue

Status

Status justification

AO-2017-118 Collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, NSW, on 31 December 2017

AO-2017-118-SI-01: There was no regulatory requirement from CASA for piston‑engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin.

Safety action still pending

AO-2017-118-SI-02: Although detectors were not required to be fitted to their aircraft, Sydney Seaplanes had no mechanism for monitoring the serviceability of the carbon monoxide detectors.

Adequately addressed

The ATSB is satisfied that the inclusion of a monthly check addresses the safety issue risk with regard to monitoring the serviceability of the carbon monoxide detectors fitted to Sydney Seaplanes aircraft.

AO-2017-118-SI-03: Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents, have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non‑identification of safety issues, which continue to present a hazard to current and future passenger-carrying operations.

Safety action still pending

AO-2017-118-SI-04: Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents, have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in important safety issues not being identified, which may remain a hazard to current and future passenger carrying operations.

Safety action still pending

Safety issue

Status

Status justification

AO-2018-006 Rotor RPM decay and hard landing involving Robinson R44, VH-HGX, 5 km south of Ayers Rock Airport, NT, on 17 January 2018

AO-2018-006-SI-01: Professional Helicopter Services did not have a calibration schedule for their passenger scales, which were under-reading. This increased the risk of their helicopters not achieving their expected take-off performance.

Adequately addressed

A calibration schedule introduced by Professional Helicopter Services addresses the safety issue risk for their other bases in addition to their Uluru Base, where the accident occurred.

AO-2018-006-SI-02: The Robinson R44 pilot’s operating handbook low rotor RPM recovery procedure did not include reference to the minimum power airspeed for the helicopter as a consideration, which may assist a pilot to recover from a low rotor RPM condition.

Not addressed

Robinson Helicopter Company have conducted two internal reviews of the safety issue and have concluded that safety action to address this safety issue is not necessary. Therefore, the ATSB have elected to close the safety issue as not addressed.

Safety issue

Status

Status justification

AO-2018-019 Fuel exhaustion and forced landing involving Cessna 441, VH-LBY, 39 km East of Broome Airport, WA, on 2 March 2018

AO-2018-019-SI-01: Although the operator had specified multiple methods of cross-checking fuel quantity gauge indications for its C441 fleet, there were limitations in the design, definition and/or application of these methods. These included:

  • The primary method used (indicated versus calculated fuel) was self-referencing in nature, and not able to detect gradual changes in the reliability of fuel quantity gauge indications.
  • Pilots did not record (and were not required to record) sufficient information on flight logs to enable trends or patterns in fuel quantity gauge indications to be effectively identified.
  • Pilots did not routinely crosscheck information from fuel quantity gauge indications with information from the independent fuel totaliser.

Adequately addressed

The ATSB is satisfied that Skippers’ amendments to, and increased focus on, fuel management policy and procedures addresses the safety issue risk with regard to the limitations of its fuel quantity assessment methods.

Safety issue

Status

Status justification

AO-2018-026 Loss of control and collision with water involving Eurocopter EC120B, VH-WII, Hardy Reef, Whitsundays, Qld, on 21 March 2018

AO-2018-026-SI-01: Although the operator complied with the regulatory requirements for training and experience of pilots, it had limited processes in place to ensure pilots with minimal time and experience on a new and technically different helicopter type had the opportunity to effectively consolidate their skills on the type required for conducting the operator's normal operations to pontoons.

Adequately addressed

The ATSB is satisfied that the action introduced by the operator, particularly the requirement to undertake 20 hours on helicopter type prior to conducting crosswind landings at pontoons, will reduce the risk of this safety issue.

AO-2018-026-SI-02: There was no requirement for operators of passenger transport flights in aircraft with six or fewer seats to provide passengers with a verbal briefing, or written briefing material, on the method for operating the emergency exits.

Adequately addressed

The ATSB notes that the requirement for briefings is limited to those seated in emergency exit rows, even for small aircraft, but overall is satisfied that the safety action taken by CASA has reduced the risk of this safety issue.

AO-2018-026-SI-03: Due to multiple factors, the design of the rear left sliding door (emergency exit) on the EC120B helicopter was not simple and obvious to use unless the occupant was provided with specific instructions about how to operate the exit. In particular:

  • the door required three actions to open (pull handle up, push door out, slide door back), and the second action was not indicated in either the design of the handle or the placard next to the handle
  • the design of the inside handle was such that its purpose may not have been readily apparent to many users.

Safety action still pending

AO-2018-026-SI-04: The operator’s system used to identify passengers with reduced mobility and/or required additional safety briefing information relied on passengers self-reporting a problem.

Partially addressed

The operator has provided more information about when and how the pilot in command must seek to identify those passengers who may require an additional safety briefing, however the operator had the same system in place at the time of the accident, whereby the operator relied on the pilot in command to identify the passengers, which in some cases would be as they were boarding the aircraft, as was the case on the day of the accident. Therefore the ATSB has assessed the safety issue as partially addressed.

AO-2018-026-SI-05: Although the operator had calibrated scales available for use at two of their check-in locations, they were not routinely used to ascertain actual passenger and/or baggage weights. Instead, the operator's personnel relied on passengers’ volunteered weights (without an additional allowance) and only weighed passengers when the volunteered weights were perceived to be inaccurate.

Adequately addressed

The ATSB is satisfied that the safety action taken by the operator has reduced the risk of this safety issue.

AO-2018-026-SI-06: There was often a significant number of birds located on the pontoons at Hardy Reef used by the operator. However, the operator did not have a process to systematically manage the risk of birdstrike. For example:

  • The operator had not conducted a formal risk assessment of the bird hazard at the pontoons.
  • The operator did not record birdstrike occurrences, which reduced its ability to accurately assess the ongoing hazard associated with birdstrikes at the pontoons. Birdstrike occurrences were also not notified to the ATSB (as required).
  • The operator did not provide guidance or appropriate equipment to enable pilots to effectively conduct visual inspections following an actual or suspected birdstrike at the pontoons.

Partially addressed

The ATSB notes that no additional action has been taken to reduce the concentration of birds at the pontoons, and that there are limited options available for reducing this concentration. However, given the location and the operational environment where the operator conducts flights (where all bird species are protected), the ATSB is satisfied that the safety action taken by the operator has reduced the risk of the safety issue.

AO-2018-026-SI-07: It was common practice for the operator’s pilots to leave the controls of their helicopter, while the rotors were turning and the friction locks applied, to escort passengers to and from the helicopter.

Partially addressed

The ATSB notes that the operator has now specified that control friction locks are not considered a suitable means of locking a control. The ATSB also notes that, according to the operator’s procedure, pilots should not be leaving the controls of a helicopter, with rotors turning, unless the helicopter was pointed into wind and the wind strength was less than 15 kt. Nevertheless, the ATSB is still concerned that the operator’s procedures will allow the pilot to leave the controls of a helicopter to escort passengers, even though CASA has advised that is not a suitable reason for doing so.

Safety issue

Status

Status justification

AO-2018-027 Controlled flight into terrain involving Kavanagh Balloons G-525, VH-HVW, Pokolbin, NSW, on 30 March 2018

AO-2018-027-SI-01: The visual flight rules permitted balloons to arrive and depart in foggy conditions without assurance that sufficient visibility existed to see and avoid obstacles.

Safety action still pending

The ATSB acknowledges CASA’s publication of the AC 131-02. The ATSB will continue to monitor this safety issue pending CASA’s risk assessment of the reduced visibility exemption to the visual flight rules for balloons, to determine whether it assures an adequate level of safety and any mitigating factors required to operate safely in those conditions.

Safety issue

Status

Status justification

AO-2018-032 Runway incursion involving Boeing 737, VH-XZM, resulting in a rejected take-off involving Boeing 737, VH-VZL, Perth Airport, WA, on 28 April 2018

AO-2018-032-SI-01: Although Qantas provided detailed guidance to flight crews about the content of departure and approach briefings, it did not specifically require aerodrome hot spots to be briefed.

Adequately addressed

The ATSB is satisfied that the action taken by Qantas addresses this safety issue.

AO-2018-032-SI-02: The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient to effectively reduce the risk of a runway incursion.

Adequately addressed

The ATSB is satisfied that the action taken by Airservices Australia and Perth Airport Pty Ltd has addressed this safety issue.

AO-2018-032-SI-03: Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combined roles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation alert or runway incursion alert at their workstation.

Adequately addressed

The ATSB is satisfied that the action taken by Airservices Australia addresses this safety issue.

Safety issue

Status

Status justification

AO-2018-049 Uncommanded Engine shutdown involving De Havilland Aircraft of Canada DHC-8, VH-LQD, 77 km north-north-west of Brisbane Airport, Qld on 26 June 2018

AO-2018-049-SI-01: The procedures in the aircraft maintenance manual relating to chip detector debris analysis were written in a way that could cause confusion and error. This probably influenced the actions of the maintenance personnel to release the aircraft to service with a deteriorating bearing.

Safety action still pending

While the safety action removes some of the ambiguity, the ATSB considers that there is still a possibility that the procedures could be misread resulting in an engine being erroneously released to service.

Safety issue

Status

Status justification

AO-2019-015 Collision with terrain involving AS350, VH-SZS, 60 km east of Woomera, SA, on 20 March 2019

AO-2019-015-SI-01: There were no requirements in Aeropower procedures to provide any post-training supervision for powerline operations. What supervision was provided was ineffective in identifying that a modified stringing method was being used by the pilot.

Adequately addressed

The actions taken by the operator address the key concern of the safety issue, that being the supervision of pilots recently trained/authorised in a new specialist task. The mandated extension of command under supervision time, the introduction of periodic consolidation flight checks, and the mandated extension of mentoring time are all expected to help better prepare newly trained pilots for solo operations and provide them with additional defences to the hazards associated with specialist flight tasks.

Safety issue

Status

Status justification

AO-2019-025 Engine power loss and collision with terrain, Bell 206B3 helicopter, VH-FHW 107 km south-west of Jabiru, NT, on 21 May 2019

AO-2019-025-SI-01: Although the Director of National Parks’ safe operating procedures required shooters and spotters to wear helmets during aerial culling tasks, helmets were not provided or used on a routine basis.

Safety action still pending

The Director of National Parks has committed to procurement of helmets and implementation of procedures for ongoing conformance to safe operating procedures and use of helmets for aerial culling tasks. This safety action will be reviewed in December 2021 or sooner if advised as completed.

AO-2019-025-SI-02: The Director of National Parks did not actively manage the risk of the aerial culling task being conducted in the Kakadu National Park, or effectively supervise the operation. As a result, an increase in the number of crew, a change in helicopter type and change of helicopter operator all progressed without requisite risk management. This exposed crew to avoidable harm during low-level aerial shooting operations.

Safety action still pending

Engaging an aviation specialist in task design has negated the immediate risk. The Director of National Parks has developed a path and committed to the necessary steps to make proactive risk management a well-supported function in planning and developing aviation activities. This safety action will be reviewed in December 2021 or sooner if advised as completed.

AO-2019-025-SI-03: Recurrency training and drills in aircraft emergencies were not required for reissue of an aerial platform shooting permission. Some shooters last conducted training about 20 years prior, during initial issue of their permissions.

Safety action still pending

The ATSB is satisfied that the proposed changes to be made on 2 December 2021 will reduce the risk of this safety issue. As this is a regulatory change, the timeframe is recognised and this safety action will be reviewed in December 2021.

AO-2019-025-SI-04: A harness instrument, commonly issued by CASA, stated that a harness could be used instead of a seatbelt for take-off and landing. Although not intended by CASA, this instrument was easily able to be misinterpreted as indicating that a seatbelt was not required to be used during take-off and landing.

Safety action still pending

The ATSB is satisfied that the proposed changes to be made on 2 December 2021 will reduce the risk of this safety issue. As this is a regulatory change, the timeframe is recognised and this safety action will be reviewed in December 2021.

AO-2019-025-SI-05: Although required by the harness instrument commonly issued by the CASA, the operator did not appraise shooting crews of the risks of using only a harness for restraint during low-level flight.

Adequately addressed

The advised changes will ensure participants are aware of the risks of using a harness at low-level. This will enable crew to make decisions around their safety with full knowledge of the risks they face.

Safety issue

Status

Status justification

AO-2019-045 Landing gear failures involving a GA8 Airvan, VH-BFS, Fraser Island, Qld, 24 August 2019 and 31 October 2019

AO-2019-045-SI-01: The operator did not place appropriate emphasis on ensuring the continuing airworthiness of the landing gear of its GA8 fleet, although being aware of:

  • the increased loads on the landing gear when routinely operating from beach landing areas up to 20–30 times daily, and being subjected to a salt-laden and humid environment
  • the axle failure of VH-BFS in 2009
  • the mandatory inspection requirements of service bulletin SB-GA8-2016-169.

Adequately addressed

The ATSB acknowledges the operator’s action regarding its changes to the control and conduct of maintenance on their aircraft. However, the ATSB notes that the prescribed maintenance program for any aircraft should be considered the minimum requirement, and when frequently operating in challenging environments such as a beach ALA additional activities or risk controls should also be considered. Nevertheless, the safety action taken by the operator has reduced the risk of this safety issue.

Safety issue

Status

Status justification

AO-2019-055 Runway incursion and take-off commenced on incorrect runway involving GIE Avions de Transport Régional ATR72, VH-VPJ, Canberra Airport, ACT, on 25 September 2019

AO-2019-055-SI-01: Virgin Australia Airlines did not require ATR flight crews to complete the before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying was critical.

No longer relevant

Due to the cessation of ATR72 operations by Virgin Australia Airlines, the ATSB has closed this safety issue as it is no longer relevant.

AO-2019-055-SI-02: Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.

Safety action still pending

Safety issue

Status

Status justification

AO-2019-060 Engine failure during take-off involving Bombardier Dash 8, VH-ZZE, at Darwin Airport, NT, on 11 November 2019

AO-2019-060-SI-01: The power turbine shaft in Pratt & Whitney Canada PW100 series engines operating in certain marine environments is susceptible to corrosion pitting, which can grow undetected between scheduled inspections. This increases the risk of shaft fracture resulting in engine failure.

Safety action still pending

Safety issue

Status

Status justification

AO-2020-036 Door failure and depressurisation involving a Cessna 441, VH-LBY near Broome, WA, on 22 July 2020

AO-2020-036-SI-01: The inspection procedures in the West Star Aviation maintenance manual supplement for extended life program Cessna 441 aircraft were inadequate to detect the progressive disbonding of the emergency exit door.

Adequately addressed

The ATSB accepts the response provided by West Star Aviation as the introduction of Textron Aviation Conquest Service Letter (CQL-99-02) supplemental inspection 52-20-03 (specific inspection details for A522005) post-dates the incident and is applicable to all the life extension aircraft.

Safety issue

Status

Status justification

AO-2020-041 Depressurisation involving a Fokker 100, VH-NHC, 167 km SSE Geraldton Airport, WA, on 10 August 2020

AO-2020-041-SI-01: While the manufacturer's instructions for the zonal inspections detailed that installation blankets could be removed 'as necessary', they did not reference the insulation blanket installation procedure. This resulted in insulation blankets not being secured to the structure.

Safety action still pending

Marine

Table 7: Marine – Responses to other safety issues identified in 2020–21

Safety issue

Status

Status justification

MO-2018-004 Grounding of bulk carrier Bulk India, Dampier, WA, on 11 March 2018

MO-2018-004-SI-01: No procedure or system was in place to ensure critical spares were identified and their inventory controlled to ensure availability when required. As a consequence, the fan belts for the emergency generator had been on order for several months.

Adequately addressed

Kowa Marine Service has put in place procedures and systems which adequately address this issue.

Safety issue

Status

Status justification

MO-2018-011 Fire on board Iron Chieftain, Port Kembla, NSW, on 18 June 2018

MO-2018-011-SI-01: Iron Chieftain's operators had formally identified the fire risk in the ship’s cargo self-unloading system spaces, particularly the C-Loop, as being unacceptably high five years before the fire due to the absence of fire detection or fixed fire extinguishing system. However, at the time of the fire, the prevention and recovery risk mitigation measures had not reduced the risk to an acceptable level.

Adequately addressed

The installation of systems to provide early heat and fire detection as well as the provision of fixed fire-extinguishing capability in the self-unloading system spaces should reduce the high level of fire risk associated with these spaces to an acceptable level.

MO-2018-011-SI-02: The cargo handling spaces of specialised self-unloading bulk carriers continue to present a very high fire risk due to the inadequacy of standards or regulations for self-unloading systems, including for conveyor belts, and dedicated fire detection/fixed fire-extinguishing systems. This has been a factor in at least three major fires over a 25-year period, including Iron Chieftain’s constructive total loss.

Safety action still pending

The ATSB acknowledges the proposals of the AMSA and Lloyd’s Register to initiate action to address this safety issue by raising it with the International Maritime Organization (IMO) and the International Association of Classification Societies (IACS), respectively. As the process of progressing safety action at IMO and IACS can be prolonged, the ATSB will monitor progress to regularly reassess the status of the safety issue and publish updates on its website.

MO-2018-011-SI-03: Iron Chieftain's Emergency Contingency Plan did not include a response plan to fire in the high fire risk self-unloading system spaces. Consequently, there was no clear plan or practised sequence of actions that could aid emergency preparedness.

Adequately addressed

The development of ship-specific emergency contingency plans for responding to fire in the self-unloading system spaces should provide a useful framework to build and improve upon. These plans, exercised in conjunction with regular and realistic emergency drills, should adequately address this safety issue.

MO-2018-011-SI-04: The capability of Fire and Rescue NSW to effectively respond to a shipboard fire in Port Kembla was limited by:

  • a lack of specialised marine firefighting expertise
  • outdated marine training for firefighters
  • relative inexperience in shipboard firefighting associated with the rarity of major shipboard fires
  • an absence of marine-specific firefighting resources and aids for use by first responders

Safety action still pending

The ATSB welcomes the action taken by Fire and Rescue NSW but considers that further action is required to adequately address the safety issue.

MO-2018-011-SI-05: Regulatory safety oversight of Iron Chieftain, which comprised flag state audits, surveys and inspections had not identified safety deficiencies with respect to the ship’s fire safety, risk management, emergency preparedness and emergency response.

Adequately addressed

The safety action taken by AMSA should serve to augment the existing regulatory oversight activity of Australian flagged ships, particularly with regard to the fire safety risk and risk management on board self-unloading ships and therefore address the identified safety issue.

Rail

Table 8: Rail – Responses to other safety issues identified in 2020–21

Safety issue

Status

Status justification

RO-2018-002 Signal ME45 passed at danger involving suburban passenger train TP43 and near collision with another suburban passenger train, Bowen Hills, Qld, on 10 January 2018

RO-2018-002-SI-02: QR’s management oversight of the Citytrain driver MOC process did not include planned assurance activities or regular and effective auditing of how the MOC assessments were being conducted, even after there were multiple indications that the process was not being conducted as designed.

Adequately addressed

The ATSB acknowledges the significant increase in assurance activities undertaken by QR in this area and is satisfied that, if such activities continue to be undertaken, the risk of the safety issue will be reduced.

RO-2018-002-SI-03: The automatic warning system (AWS) provided the same audible alarm and visual indication to a driver on the approach to all restricted signals (that is, double yellow, yellow, flashing yellow and red aspects). The potential for habituation, and the absence of a higher priority alert when approaching a signal displaying a red aspect, reduced the effectiveness of the AWS to prevent signals passed at danger (SPADs). This placed substantial reliance on procedural or administrative controls to prevent SPADs, which are fundamentally limited in their effectiveness.

Partially addressed

The ATSB notes the safety action to change the auditory volume of the AWS for restricted signals versus green signals, but believes that this will not have a significant impact in reducing the risk of the safety issue as it does not help differentiate red signals from other restricted signals. The ATSB also appreciates that there would be substantial difficulty in redesigning the AWS to provide a clear distinction between the alerts that occur in response to signals with a red aspect compared to other restricted signals. However, the ATSB welcomes the safety action to introduce the European Train Control System (ETCS) and believes that this system will reduce the risk of SPADs where and when it is implemented.

RO-2018-002-SI-04: After mandating the use of risk triggered commentary driving (in 2011) to mitigate the risk of signals passed at danger, Queensland Rail Citytrain did not provide the necessary support to its trainers, assessors and drivers to effectively maximise the potential benefits of the technique and minimise the potential limitations or risks associated with the technique.

Adequately addressed

The ATSB notes the safety action already undertaken and being undertaken to clarify the requirements of risk triggered commentary driving (RTCD) and facilitate more consistent application of the technique, and to simplify some of the recommended word strings. The ATSB still has concerns about potential problems with the mandatory nature of the technique in all situations. However, overall the ATSB is satisfied that the safety action undertaken and being undertaken will reduce the risk of this safety issue.

RO-2018-002-SI-05: Prior to the SPAD occurrence in January 2018, Queensland Rail did not routinely and systematically analyse recorded data to determine driver compliance with key operational rules that had been designed to minimise the risk of SPADs.

Adequately addressed

The ATSB acknowledges the significant increase in activity that QR has undertaken in this area since 2017. Although the ATSB notes that there are some limitations with the data for measuring compliance rates with some SPAD mitigation rules, the ATSB is satisfied that the action undertaken by QR has reduced the risk of this safety issue, and that the risk of this safety issue would be further reduced with the introduction of automatic event recorder analytics software.

Safety issue

Status

Status justification

RO-2018-008 Track obstruction due to loss of freight involving train 6WM2 and subsequent impact of passenger train 8615 with track obstruction, near Winton, Vic, on 30 March 2018

RO-2018-008-SI-01: Pacific National's Freight Loading Manual, specific to the loading and unitising of jumbo coils, did not require the use of rubber load mat on cradles. Consequently, there was no requirement to consider the condition of load mat during inspection and maintenance. This allowed the continued use of cradles without load mat, which decreased their effectiveness at restraining loads.

Adequately addressed

The routine inspection of rubber load mats fitted to cradles carrying jumbo coils will allow Pacific National to maintain the condition of the mats sufficient to reduce the risk of the load restraint capabilities being compromised.

RO-2018-008-SI-02: Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of strap breakage due to contact with the cradle.

Partially addressed

Pacific National has not implemented any actions to prevent coils from being 'loaded in an orientation where all the radial straps are positioned within the contact zone between the coils and cradle'.

However, the responses provided by Pacific National do include other actions (ensuring that coil cradles are fitted with rubber mat and requiring the condition of the mat to be inspected and maintained) that address the risk of straps breaking. In addition, Pacific National has undertaken to continue to 'further investigate and explore options to reduce the risk of ... the radial straps becoming damaged from coming into contact with the cradle, so far as is reasonably practicable'. Based on this, the ATSB is satisfied that the requirement for, and ongoing maintenance of, rubber matting will assist in reducing the risk of the unitising straps breaking.

RO-2018-008-SI-03: Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose.

Adequately addressed

Pacific National has indicated it believes, based on calculations and measured data, that its jumbo coil carrying demountable cradles provide, at minimum, restraint capable of resisting about 0.75 g acceleration. This was greater than the actual accelerations measured by instrumentation during operation, at about 0.3 g typical (0.372 g maximum peak).

Therefore, Pacific National stated that the level of load restraint offered by current demountable cradles demonstrates that they sufficiently restrain jumbo coils against lateral accelerations and prevent coils from moving and falling during transit.

The ATSB acknowledges that Pacific National has provided a demonstration that the demountable cradle design is safe and fit for purpose.

RO-2018-008-SI-04: Pacific National's Freight Loading Manual did not require the use of radial unitising straps to prevent telescoping on jumbo coils where the thickness of the steel was greater than 2 mm.

Adequately addressed

The ATSB is satisfied that the use of a minimum of two radial unitising straps on jumbo coils will reduce the risk of telescoping during transit.

Safety issue

Status

Status justification

RO-2018-009 Derailment of freight train 6MP4 near Glenalta, SA, on 21 April 2018

RO-2018-009-SI-01: Pacific National’s inspection processes did not identify key structural points for inspection on RRYY class wagons, including the susceptibility to cracking in the junction between container loading outriggers, pull rod boxed opening, and the bottom centre sill sections. This reduced the likelihood of cracks being detected.

Adequately addressed

The ATSB is satisfied that the action taken by Pacific National will ensure that maintenance inspections and train examinations will be directed to key areas of the RRYY wagon design that are susceptible to cracking.

Safety issue

Status

Status justification

RO-2018-011 Derailment involving freight train YC77, Cooroy, Qld, on 18 August 2018

RO-2018-011-SI-01: Aurizon did not have an effective system in place for ensuring personnel required to check the securing of unusual loads (such as empty flat racks) prior to departure had sufficient knowledge of their responsibilities, and had ready access to relevant procedures, guidance and checklists.

Adequately addressed

The ATSB is satisfied that the safety action taken by Aurizon will reduce the risk of this safety issue in the areas under its influence.

RO-2018-011-SI-02: Aurizon did not provide drivers with ready access to Queensland Rail’s procedures for driver only operations and overhead line equipment emergencies when they were operating on the Queensland Rail network. In addition, Aurizon did not have procedures for driver only operations that applied to its own network.

Adequately addressed

The ATSB is satisfied that the safety action taken by Aurizon will reduce the risk of this safety issue.

RO-2018-011-SI-03: Queensland Rail did not have an effective process in place to ensure that safety-critical actions were coordinated and completed when multiple network control officers were involved in responding to an overhead line equipment emergency.

Safety action still pending

Safety issue

Status

Status justification

RO-2019-002 Level crossing irregularity involving passenger train 3MA8, North Geelong, Vic, on 8 January 2019

RO-2019-002-SI-01: VicTrack’s contractor, UGL Engineering Limited, did not provide signalling testers with specific instructions detailing the scope of work to be conducted at each stage of a project, but rather, only provided packaged isolation plans for the entire project. The absence of these instructions increased the risk of the works being incorrectly implemented.

Adequately addressed

The ATSB is satisfied that the action taken by VicTrack will reduce the risk of works being incorrectly implemented in relation to isolation plans.

Safety issue

Status

Status justification

RO-2019-003 Derailment of freight train 6BM9 at Creighton, Vic, on 21 January 2019

RO-2019-003-SI-01: The ARTC systems for managing track lateral stability did not lead to the location being managed as a location potentially vulnerable to instability.

Safety action still pending

Safety issue

Status

Status justification

RO-2019-013 Derailment of loaded Pacific National coal service TM94, near Moss Vale, NSW, on 28 June 2019

RO-2019-013-SI-01: Axle testing on wheelset number 7E5S 831444 was not carried out during the two most recent wheelset maintenance events in January 2016 and November 2016. It is likely the axle crack existed at the time of these maintenance activities.

Adequately addressed

ATSB is satisfied that the actions taken by Pacific National have addressed the safety issue.

RO-2019-013-SI-02: Inspection records for the December 2010 wheelset maintenance activity and wheel change on wheelset number 7E5S 831444 were not available. It is a requirement specified in Pacific National's Wagon Maintenance Manual that records be retained for a period of 12 years.

Adequately addressed

ATSB is satisfied that the actions taken by Pacific National have addressed the safety issue.

Safety issue

Status

Status justification

RO-2019-014 Near miss with maintenance worker on Skitube Alpine Railway, Bullocks Flat, NSW, on 3 July 2019

RO-2019-014-SI-01: The Skitube system for managing access to track did not detect the conflict of the rail maintenance worker under the train at the same time the train was being shunted.

Adequately addressed

Re-iteration of the procedure and form requirements has merit in keeping current employees aware of the procedures’ purpose.
Re-iteration of these requirements would be required at regular intervals to maintain awareness of the risks controlled by the procedures. A refresher of the safe working rules and procedures prior to each operating season would achieve this.

RO-2019-014-SI-02: Elements of the safety and environment management system are reliant on procedures being followed to manage safety risks. There is little scope for the system to recover when there has been a human error or other procedural error.

Partially addressed

A broadcast radio call to make all operations staff aware of a red flagged train and its whereabouts provides another layer of control to strengthen existing controls. The requirement to confirm all controls are in place decreases the opportunity for a procedural error to occur. The Safeworking Check is a suitable method of monitoring compliance with procedures. The process for implementing independent verification of work when returning vehicles to service will be monitored.

RO-2019-014-SI-03: The system of placing protection flags on both ends of a train set does not provide a positive isolation of energy to ensure a train cannot be moved while it is being worked on.

Adequately addressed

The requirement to lower the pantograph and the additional, brakes applied, keys removed and driver’s cab locked with do not operate tag placed on the driver cab effectively isolates power from the train. Locking the driver’s cab and placing the do not operate tag is an effective mechanism of stopping another person from re-powering and moving a train without understanding why the cab is locked and the do not operate tag is in place.

Safety issue

Status

Status justification

RO-2020-005 Uncontained battery failure involving Sydney Light Rail Vehicle 053, Randwick LRV Depot, NSW, on 3 April 2020

RO-2020-005-SI-01: Neither Alstom’s validation processes nor fault monitoring processes were sufficient to detect the overcharging of batteries prior to the event.

Adequately addressed

The ATSB is satisfied that the safety actions taken by Alstom will reduce the risk of this safety issue.

Safety issue

Status

Status justification

RO-2020-006 Near hit with rail worker by passenger train 283D, Dora Creek, NSW, on 9 May 2020

RO-2020-006-SI-01: There was an unapproved practice occurring during Track Work Authority of asking the Outer Handsignaller to remove Railway Track Signals from the track as a train was closely approaching in order to let it run free, which placed the Outer Handsignaller at risk of being struck by the train.

Safety action still pending

Sydney Trains has included this issue in their change request process for Network Rules. The amendment will be to reinforce the existing requirement in step 12 of NPR 702 as it relates to a TWA using an inner and outer handsignaller protection, in that both the inner and outer protection must be replaced immediately after the passage of each rail traffic movement.