Recommendations and Safety Advisory Notices

Safety issue
The process for identifying potential rail defects is limited by the ultrasonic test vehicle operator's ability to detect and assess the echo patterns correctly.

Action taken by the ARTC
Rail Technology International (RTI) is actively conducting further development of their ultrasonic testing process. For example, RTI are developing software based on 'Artificial Neural Networks' for recognising ultrasonic reflection patterns that represent potential rail defects such as bolt-hole cracks. RTI have conducted post test re-analysis of ultrasonic test data using the neural network software to identify any defects that may have been missed during the test run. RTI's plan is to run the neural network software in the background and conduct this analysis while ultrasonic testing is being undertaken. RTI have indicated that implementation is planned for early 2010.

ATSB assessment of action
The ATSB acknowledges that the ARTC and RTI are developing processes to reduce the risks associated with operator dependence. While some of those
initiatives have been introduced, especially in relation to bolt-hole cracks, other rail defects are also exposed to the issue of operator dependence. The opportunity exists for continued development and implementation of strategies aimed at reducing operator dependence.

ATSB safety advisory notice RO-2008-005-SAN-035
The Australian Transport Safety Bureau advises that the ARTC should consider the implications of this safety issue and take action where considered appropriate.

Safety Issue
The ARTC Code of Practice does not recognise the relationship between heataffected metal and stress concentration when specifying how far a bolt-hole should be from the rail ends before welding.

ATSB safety advisory notice RO-2008-005-SAN-036
The Australian Transport Safety Bureau advises that the ARTC should consider the implications of this safety issue and take action where considered appropriate.

Safety issue

The ARTC Code of Practice does not clearly address the possibility that a series of track irregularities, even minor ones which do not exceed intervention limits, could cause an undesirable harmonic response in some rail vehicles.

ATSB safety recommendation

The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes safety action to address this safety issue.

Safety Issue

The trailing bogie of wagon RCPF-31882C was found to have loose and broken wedge wear plates. It could not be verified whether the wedge wear plates had broken free before or during the derailment sequence. However, if the condition had existed prior to the derailment, it is likely that body roll induced while traversing a series of track irregularities could result in undamped harmonic oscillations.

ATSB safety recommendation

The Australian Transport Safety Bureau recommends that Pacific National takes safety action to address this safety issue.

Safety issue

Examination of wagon RCPF-31882C revealed a crack on the tread of a wheel on the second axle of the leading bogie. While not contributing to this derailment, if the crack were to develop to such an extent that the wheel tread completely fractured, the risk of derailment would increase significantly.

Safety recommendation

The Australian Transport Safety Bureau recommends that Pacific National takes safety action to address this safety issue.

Safety Issue

Both the 6 hours on/6 hours off work routine for watchkeepers and the modified work routine for deck ratings used on board Thor Gitta, while
complying with the ILO 180 and STCW requirements for rest, probably resulted in a cumulative level of fatigue in the crew.

Response from the Danish Maritime Authority

The Danish Maritime Authority recognises the use of programs like FAID to indicate the possibility of fatigue, but regards the indications given by such programs only as normative and not as given proof.

It is the opinion of the Danish Maritime Authority that the 6 hours on/off work routine for watchkeepers and the modified routine for deck ratings on board Thor Gitta does not constitute a problem as long as the hours of rest are in compliance with the Order, ILO Convention 180 and part A, Chapter VIII of the STCW code for crewmembers engaged in watchkeeping.

The Danish Maritime Authority disagrees with the statements indicating that the roster of the AB and the work routine for watchkeepers probably results in a cumulative level of fatigue in the crew.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Danish Maritime Authority undertake further work to address this safety issue.

The DMA has, in 2008, established a procedure on examination of rest and work hours, as well as outlook whenever a Danish or Greenlandic ship is involved in grounding or collision or has a very serious accident.

In these cases, the Investigation Division gather relevant information and evaluate the information before forwarding them to various departments within the DMA for further consideration. The considerations focus on whether there have been violations of rules in force. Consideration is also focusing on questions in relation to the manning of ships and possible need of changes.

Safety issue

Manual systems of train management, such as Special Proceed Authority working, are used when interlocked/engineered systems are not available. However, manual systems are subject to human error and increase the risk of safeworking irregularities/incidents when compared to interlocked/engineered systems of safeworking.

Response from the ARTC

Special Proceed Authorities (SPAs) are a paper-based safe working system, not unlike Train Orders. Paper-based systems such as Train Orders are used to authorise train movements over a significant part of Australia's national rail network. The incident at Tarana occurred in the execution of the SPA, not as a result of a problem with the safe working system.

ATSB assessment of response

The Australian Transport Safety Bureau notes ARTC's response, however the risk of safeworking irregularities is greater with manual systems of safeworking. The ATSB urges the ARTC to explore further opportunities to mitigate the risks of human error when using a paper-based system in addition to considering alternative risk controls that may reduce or eliminate human error.

Safety recommendation

The Australian Transport Safety Bureau recommends that the ARTC take action to address this safety issue.

Safety isssue

MSC Lugano's safety management system gave the master no guidance as to how long to wait before entering the engine room following the release of carbon dioxide into the space.

Safety Advisory Notice

The Australian Transport Safety Bureau advises that owners, managers and masters should consider the safety implications of this safety issue and to take action where considered appropriate.

Safety advisory notice

The Australian Transport Safety Bureau draws the attention of all operators to the contributory and other factors identified by this investigation. Operators are encouraged to review their procedures to ensure an appropriate awareness amongst operating personnel of the implications for aircraft performance of the combination of aircraft weights and speed, and of the ambient conditions.

Safety Issue

Saldanha's master and crew were not aware of the appropriate first aid treatment required for burn injuries. As a result, the third engineer was not immediately provided with appropriate first aid.

Safety Advisory Notice

The ATSB advises that flag States, owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.

Safety Issue

While the Volcano Company safety bulletin warned of the dangers associated with servicing the VJ type burner, it did not inform operators that the burner could be replaced with a VJP burner (a similar burner fitted with a diesel pilot burner), or recommend that existing oil firing units could be modified.

Safety Recommendation

The ATSB recommends that the Volcano Company takes safety action to address this safety issue.

Safety Action

The Volcano Company has advised the ATSB that they will;

1. Advise all operators of the occurrence on board the bulk carrier Saldanha.

2. Advise all operators of the importance of adhering to the safety bulletin, regardless of the type of burner, and the fact that if the operation and servicing are not done as per our safety bulletin, ship crews will be exposed to the same risks as those seen on board Saldanha.

3. Advise all operators that the "VJ" burner is  a direct ignition type and that there is also another type of burner "VJP" fitted with pilot burner. If operators wish to have their burner fitted with a pilot burner, Volcano will advise them that the existing burner could be replaced with VJP type burner or that it can be modified.

4. We will also put the same advice on our homepage for a period of time.

Safety issue

Iron King's safety management system did not include procedures that adequately ensured that the ship's master and crew were aware of, and drilled in, the emergency steering system change over procedure to be followed in the event of steering control loss.

Safety Advisory Notice

The Australian Transport Safety Bureau advises that owners, operators and masters should consider the safety implications of this safety issue and take action where considered appropriate.

Safety Issue

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.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Port Adelaide Enfield City Council takes action to address this safety issue.

Lack of Interface Agreement, Stirling Street Level Crossing
The Port Adelaide Enfield City Council has advised that the recommendation is accepted. The Council is awaiting the drafting of Interface Agreements by the SA State Level Crossing Advisory Committee. Also, the Council has advised that they are currently working with the Department of Transport, Energy and Infrastructure's (DTEI) Level Crossing Unit in relation to DTEI's survey and assessment of level crossings in SA.

Safety issue

At the time of the collision and at times in the past, the required road pavement markings have not been present or appropriately maintained on the sealed surface of Stirling Street.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Port Adelaide Enfield City Council takes action to address this safety issue.

Pavement Markings, Stirling Street Level Crossing
The Port Adelaide Enfield City Council has advised that the recommendation is accepted. The Council has advised that immediately after the Department of Transport, Energy and Infrastructure (DTEI) works associated with the Port River Bridge were completed that the pavement line marking was completed by agencies other then the Port Adelaide Enfield City Council.

Safety Issue

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.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes action to address this safety issue.

The ARTC accepts the above recommendation. The ARTC has been working towards establishing an interface agreement with the SA Department for Transport, Energy and Infrastructure for several years. It is anticipated that once a model agreement is established negotiations  with Local Government agencies will progress at a significantly faster rate.

Negotiations with Local Government organisations if not progressed as a block via the Local Government Association will need to be progressed by individual negotiation with each interfacing Council.

If the latter situation is the case ARTC reserves the right to prioritise negotiations based on a number of interfaces and perceived risk to the safety of rail operations.

Safety Issue

The Australian Rail Track Corporation had not been approached as part of the SA Department for Transport, Energy and Infrastructure's (DTEI) process of issuing Heavy Vehicle Permits for routine 'fixed term' Restricted Access Vehicle operations. Consequently, the process may preclude the opportunity to determine all risks associated with a railway level crossing, or identify changes to a railway level crossing risk profile that may have occurred over a period of time.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Department for Transport, Energy and Infrastructure take further action to address this safety issue.

• Non general access vehicles, such as B-Doubles, can access parts of the road network if provided with an exemption from the mass and / or dimension limits of the Road Traffic Act by a permit or through a general exemption via a government gazette notice.
• Under the Department's Heavy Vehicle Access Framework, which was updated in April 2009 (see www.transport.sa.gov.au), exemptions by permit are now only being provided in limited circumstances, generally on a one off basis.
• DTEI is currently reviewing all routes where permits are being used to provide access over level crossings. The objective of this review is to identify works required to upgrade the route so that there is no longer a need to issue permits for access but to have the route exemption provided by government gazette notice subject to rail authority agreement.
• In addition, DTEI currently undertakes a rolling level crossing survey and assessment program which sees each individual crossing re-assessed approximately once every three years. Any issues that are found during the assessment process is brought to the attention of the relevant infrastructure manager.
• In relation to Stirling Street, DTEI has worked with the ARTC to ensure all issues have been addressed. DTEI is currently in the process of securing ARTC agreement to have route gazetted thereby eliminating the need for permits.

Safety Issue
The work permit system had not been effectively implemented on board the ship. Consequently, most maintenance and repair work was being carried out by ship's personnel without the work permits and 'Danger: Do Not Operate' tags that were required by the ship's procedures.

Safety Recommendation

ATSB recommends that the Parakou Shipping undertake further action to address this safety issue.

Safety issue

There was no regulatory requirement for simulator training in Australia.

Action taken by the Civil Aviation Safety Authority

A summary of CASA activities to facilitate the use of full flight simulators and/or flight training devices follows:

The following inter-related activities are in the process of implementation:

• A combined workshop activity with Ansett Aviation Training, Capiteq Limited trading as AirNorth, Network Aviation Pty Ltd, Skippers Aviation Pty Ltd, PelAir Aviation Pty Ltd and CASA was held on 27, 28 April 2009.
• CASA has initiated a review of CAR 217 Training Organisations and Training Centres. This programme of review was prompted following investigations that revealed AOC holder training inconsistencies.
• A Component of the 'CAR 217 Training Organisations and Training Centres Special Emphasis Review' is to establish the level of company oversight and involvement with training and simulation, programmes that have been outsourced.
• Civil Aviation Order 40.2.1 - Instrument Rating, Section 12A, `Renewal using an overseas flight simulator training provider' has been added to include the option of instrument proficiency checks being conducted by an overseas simulator provider. This is to enable an instrument rating renewal where a specific type simulator is not available in Australia:
  • This amendment needs to read in conjunction with Advisory Circular AC 60-2 (1) of May 2007;
  • The Advisory Circular identifies that CASA recognises the flight simulator qualifications certificates issued by Canada, Hong Kong (Special Administrative Region of China), New Zealand, the United States of America, Belgium, the Czech Republic, Denmark, Finland, France, Germany, Ireland, Italy, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and the United Kingdom; and
  • Civil Aviation Order 40.1.0 - Aircraft Endorsement - Aeroplanes, Section 6. This facilitates an option for instrument rating renewals to be associated with the issue of an aircraft type rating.

ATSB assessment of response/action

The activities undertaken by CASA appear to have facilitated increased use of simulators for endorsement and other training. However, the ATSB remains concerned that there is no regulatory requirement for simulator training when a suitable simulator is available in Australia.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety issue.

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.

This work will commence immediately.  It will involve consultation with industry and may come to involve a risk assessment, a cost-benefit analysis, and the preparation of a regulatory impact statement.  As this is likely to be a protracted process, CASA is not in a position to specify a specific completion date at this time.

Safety Issue

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 Practrice. 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.

Action taken by WestNet Rail

WestNet Rail has advised:

A complete review of WestNet Rail's ultrasonic testing regime is being conducted by Monash University's Institute of Railway Technology to ensure best practice is being followed.

WestNet Rail has also advised that it is establishing an electronic track asset management system.

ATSB assessment of action

The Australian Transport Safety Bureau notes that WestNet Rail has taken action in response to this safety issue. These actions are still in the formative stage. WestNet Rail does not yet have systems in place that address the specific safety issue.

Safety Recommendation

The Australian Transport Safety Bureau recommends that WestNet Rail takes action to address this safety issue.

Safety Issue

There was no clear guidance within the WestNet Rail rules for train crews that defined an allowable speed associated with proceeding 'cautiously'. Had the train been travelling at a slower speed it is probable that the extent of damage caused by the derailment would have been less.

Action taken by WestNet Rail RO-2007-006-NSA-007

WestNet Rail has advised:

Immediately after the derailment WestNet Rail implemented, on the 47 kg/m track equipped with CTC, between Koolyanobbing and West Kalgoorlie, the following instruction - Upon any unexplained illumination of a track or block section in the above section the Train controller must not permit any train to enter the section concerned until the Infrastructure person and the Safeworking Technician on call have both been advised and attended to ascertain the cause and corrective action implemented.

The above instruction applies 24 hours a day until further notice.

ATSB assessment of action

The Australian Transport Safety Bureau notes that WestNet Rail has taken action in response to this safety issue. However, WestNet Rail has not addressed the lack of guidance within their rules for train crews who are requested to proceed 'cautiously'. WestNet Rail's rules in this regard are not best practice when compared to rules in other rail systems.

Safety Recommendation

The Australian Transport Safety Bureau recommends that WestNet Rail undertake further work to address this safety issue.