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Amendments to Appendix 7 (19 Nov 2002) : Status of Transport Safety Recommendations and Safety Advisory Notices Issued By The Australian Transport Safety Bureau in 2001-02

This appendix provides detailed information on the status of safety recommendations and safety advisory notices issued by the Australian Transport Safety Bureau (ATSB) in 2001-02.

Aviation

Under existing memoranda of understanding, both the Civil Aviation Safety Authority and Airservices Australia have agreed to respond to the ATSB within 60 days of the date of issue of any safety recommendations. No other organisations are obliged to respond but a nominal 60 day due date is listed and any response received is published.
On some occasions a response is made to a draft safety output. This situation may result in a response date being prior to the formal issue date.

In 2001-02, ATSB issued 42 recommendations and 29 of those received a response. Of the responses four were 'closed-accepted', three were
'closed-partially accepted', 17 are being monitored, three remain open, and two were 'closed-not accepted'.

The Bureau also issued 10 safety advisory notices. Responses are not required for these.

Marine

Five investigation reports completed in 2001-02 contained safety recommendations. There is no regulatory requirement for the shipping industry to respond to these.

Rail

The ATSB released three rail investigation reports all of which included recommended safety actions.

The ATSB conducts rail investigations at the request of State/Territory authorities under State/Territory legislation. While the Bureau provides the completed investigation report to these authorities, formal arrangements regarding responses to recommendations are a matter for the authorities concerned.

Table 26: Summary of Australian Transport Safety Bureau recommendations issued to the aviation industry in 2001-02 (including responses received up to 30 June 2002)

Recommendation

Issue Date

Receiving Organisation

Response Due Date

Status of Response

R20000189
The ATSB recommends that Bell Helicopter Textron Inc. revise the maintenance manual for the Bell 206B III series helicopter to require the lubrication of the hydraulic pump drive splines on a calendar basis regardless of the time in service of the helicopter.
3 Dec 2001 Bell Helicopter Co 1 Feb 2002
No response at 30 Jun 2002
R20000191
The ATSB recommends that the Federal Aviation Administration note the findings of this accident. It also recommends that the Federal Aviation Administration alert all operators of Bell 206B III series helicopters of the deficiency in the maintenance manual.
3 Dec 2001 United States Federal Aviation Administration 1 Feb 2002
No response at 30 Jun 2002
R20000301
The ATSB recommends that Airservices Australia review the documentation in relation to air traffic controller recency requirements, in particular, the methodology of how individuals can meet the requirements.
19 Oct 2001 Airservices Australia 18 Dec 2001
Received 3 Oct 2001
Open
R20000302
The ATSB recommends that the Civil Aviation Safety Authority review the requirements for air traffic controller recency and specify the number of hours required, the shifts that do or do not qualify for such recency, and the documentation for recording such recency.
19 Oct 2001 Civil Aviation Safety Authority

18 Dec 2001

CASA response
received 10 Oct 2001

Airservices Australia response received 3 October 2001

Open
R20010072
The ATSB recommends that the Civil Aviation Safety Authority publish information for the guidance of operators and pilots regarding the correct procedures for simulating engine failures in turbo-propeller aircraft.
20 Dec 2001 Civil Aviation Safety Authority 18 Feb 2002
Received 2 Jan 2002
Monitor

R20010085
The ATSB recommends that the Civil Aviation Safety Authority review the potential side effects on humans of the cocktail of HFC-134a refrigerant, in its gaseous form, and the associated lubricant. If that review finds the use of such materials is significantly adverse to human health, the use of HFC-134a refrigerant and its associated lubricant as an airconditioning refrigerant in pressurised aircraft should also be reviewed.

11 Dec 2001 Civil Aviation Safety Authority 9 Feb 2002
Received 22 Feb 2002

22 Feb 2002

Closed - Partially accepted.

R20010086
The ATSB recommends that the Federal Aviation Administration of the United States review the potential side effects on humans of the cocktail of HFC-134a refrigerant, in its gaseous form, and the associated lubricant. If that review finds the use of such materials is significantly adverse to human health, the use of HFC-134a refrigerant and its associated lubricant as an airconditioning refrigerant in pressurised aircraft should also be reviewed.
11 Dec 2001 United States Federal Aviation Administration 9 Feb 2002
No response at 30 Jun 2002
R20010087
The ATSB recommends that Raytheon Aircraft Company review the potential side effects on humans of the cocktail of HFC-134a refrigerant, in its gaseous form, and the associated lubricant. If that review finds the use of such materials is significantly adverse to human health, the use of HFC-134a refrigerant and its associated lubricant as an airconditioning refrigerant in pressurised aircraft should also be reviewed.
11 Dec 2001 Raytheon Aircraft Company 9 Feb 2002
No response at 30 Jun 2002

R20010121
The ATSB recommends that General Electric Aero Engines:

  • review the suitability of using Inconel 625 alloy consumables during the weld repair of high pressure turbine blades

  • review the life estimate and inspection intervals for high pressure turbine blades repaired under the procedures using Inconel 625 alloy consumables

  • notify all operators using CFM56-2C, CFM56-2A/2B, CFM56-3 or similar engines of the possibility of catastrophic engine failure due to failure of high pressure turbine blades repaired using Inconel 625 alloy consumables.

25 Oct 2001 General Electric USA 24 Dec 2001
No response at 30 Jun 2002

R20010122
The ATSB recommends that the US Federal Aviation Administration:

  • review the life estimate and inspection intervals for high pressure turbine blades repaired under the procedures using Inconel 625 alloy consumables

  • notify all operators using CFM56-2C, CFM56-2A/2B, CFM56-3 or similar engines of the possibility of catastrophic engine failure due to failure of high pressure turbine blades repaired using Inconel 625 alloy consumables.

25 Oct 2001 United States Federal Aviation Administration 24 Dec 2001
No response at 30 Jun 2002
R20010123
The ATSB recommends that the Civil Aviation Safety Authority notify all operators using CFM56-2C, CFM56-2A/2B, CFM56-3 or similar engines of the possibility of catastrophic engine failure due to failure of high pressure turbine blades repaired using Inconel 625 alloy consumables.
3 Dec 2001 Civil Aviation Safety Authority 1 Feb 2002
Received 20 Mar 2002
Closed - Accepted
R20010124
The ATSB recommends that the Civil Aviation Safety Authority advise the aviation industry of the potential side effects on humans of the cocktail of HFC-134a refrigerant, in its gaseous form, and the associated lubricant.
11 Dec 2001 Civil Aviation Safety Authority

9 Feb 2002
Received 22 Feb 2002

Closed - Partially accepted
R20010133
The ATSB recommends that the Civil Aviation Safety Authority, in conjunction with appropriate specialist organisations, develop and promulgate requirements that specify which fuel cylinder fittings are suitable for use in balloons, and suitable configurations for those fittings.
13 Aug 2001 Civil Aviation Safety Authority 12 Oct 2001
Received 4 Mar 2002
Monitor

R20010134
The ATSB recommends that the Civil Aviation Safety Authority ensure that balloon owners and operators identify and remove gas tank fittings that are not suitable for balloon operations.

13 Aug 2001 Civil Aviation Safety Authority 12 Oct 2001
Received 4 Mar 2002
Closed - Accepted
R20010168
The ATSB recommends the Civil Aviation Safety Authority conduct a review of all Boeing jet aircraft maintenance documentation to ensure completeness of main cabin door escape slide deactivation and activation to return to service following maintenance action.
7 Nov 2001 Civil Aviation Safety Authority

6 Jan 2002

Received 11 Sep 2001

2nd response
6 Mar 2002

Monitor
R20010185
The ATSB recommends that the Australian Parachute Federation advise its members of the need to use exit techniques and positions that avoid any contact between the parachute container and the aircraft.
22 Apr 2002 Australian Parachute Federation 21 Jun 2002
No response at 30 Jun 2002
R20010186
The ATSB recommends that the Australian Skydiving Association advise its members of the need to use exit techniques and positions that avoid any contact between the parachute container and the aircraft.
22 Apr 2002 Australian Skydiving Association 21 Jun 2002
No response at 30 Jun 2002
R20010187
The ATSB recommends that the Civil Aviation Safety Authority, the Australian Parachute Federation and the Australian Skydiving Association review the safety advantages of requiring pilots, where practicable, to wear parachutes during parachute operations.
22 Apr 2002 Australian Parachute Federation 21 Jun 2002
No response at 30 Jun 2002
R20010187
The ATSB recommends that the Civil Aviation Safety Authority, the Australian Parachute Federation and the Australian Skydiving Association review the safety advantages of requiring pilots, where practicable, to wear parachutes during parachute operations.

22 Apr 2002 Australian Skydiving Association 21 Jun 2002
No response at 30 Jun 2002
R20010187
The ATSB recommends that the Civil Aviation Safety Authority, the Australian Parachute Federation and the Australian Skydiving Association review the safety advantages of requiring pilots, where practicable, to wear parachutes during parachute operations.
22 Apr 2002 Civil Aviation Safety Authority 21 Jun 2002 Received 24 May 2002 Closed - Accepted
R20010192
The ATSB recommends that the Civil Aviation Safety Authority assess the adequacy of the Turbomeca Arriel engine MO3 bearing lubrication installation to determine if it meets the applicable design standard requirements to ensure the continued airworthiness of relevant Australian registered aircraft.
18 Sep 2001 Civil Aviation Safety Authority

17 Nov 2001

Received 25 Feb 2002

2nd response received 22 Mar 2002

Closed - Not accepted
R20010193
The ATSB recommends that the Direction Generale de l'Aviation Civile (DGAC) assess the adequacy of the Turbomeca Arriel engine MO3 bearing lubrication installation to determine if it meets the applicable design standard requirements.
18 Sep 2001 Direction General de L'Aviation Civile 17 Nov 2001
Received 15 Jan 2002
Monitor
R20010195
The ATSB recommends that the Civil Aviation Safety Authority consider proposing an increase in the operations' classification, and/or the minimum safety standards required, for organisations that transport their own employees and similar personnel (for example contractors, personnel from related organisations, or prisoners, but not fare-paying passengers) on a regular basis. This recommendation applies to all such operations, regardless of the take-off weight of the aircraft involved.
7 Sep 2001 Civil Aviation Safety Authority 6 Nov 2001
Received 4 Feb 2002
Monitor
R20010196
The ATSB recommends that the Civil Aviation Safety Authority take appropriate action to ensure the continued airworthiness of Australian registered aircraft fitted with Turbomeca Arriel engines incorporating modification TU204.
18 Sep 2001 Civil Aviation Safety Authority 17 Nov 2001
Received 25 Feb 2002
Monitor
R20010197
The ATSB recommends that the Direction Generale de l'Aviation Civile take appropriate action to ensure the continued airworthiness of aircraft fitted with Turbomeca Arriel engines incorporating modification TU204.
18 Sep 2001 Direction General
de L'Aviation Civile
17 Nov 2001
Received 15 Jan 2001
Closed - Partially accepted
R20010202
The ATSB recommends that the Civil Aviation Safety Authority review the need to develop and mandate competency standards for low-level aircraft operations, including powerline inspection by helicopters.
26 Feb 2002 Civil Aviation Safety Authority

26 Apr 2002
Received 17 May 2002

Monitor
R20010203
The ATSB recommends that the Civil Aviation Safety Authority consider instituting an education program for the industry highlighting the impending changes to operational standards to be introduced under Civil Aviation Safety Regulation (CASR) Part 61 and its associated elements, in order to give sufficient lead time for early adoption and implementation.
26 Feb 2002 Civil Aviation Safety Authority 27 Apr 2002
Received 17 May 2002
Monitor

R20010204
The ATSB recommends that Electricity Supply Association of Australia (ESAA) in conjunction with its members develop formal Operations and Procedures Manuals to be used by Australian Electrical Supply Businesses employing helicopters to accomplish low level power line inspection or maintenance tasks. These manuals should take into consideration appropriate elements of the guidelines laid down in the ESAA handbook: "Guidelines to Helicopter live power line work." These manuals should have an appropriate quality control audit procedure to ensure that industry accepted best practice
is maintained.

26 Feb 2002 Electricity Supply Association of Australia 27 Apr 2002
Received 17 Apr 2002
Monitor

R20010205
The ATSB recommends that Electricity Supply Association of Australia (ESAA) in conjunction with its members and in consultation with helicopter operators identified as successful tenderers for low level power line survey work, adopt or purchase an acceptable training package to be undertaken by any power supply company employees prior to tasking on helicopter power line inspection. This training package should include but not be limited to:

Safety hazards when working in and around helicopters; In flight communication procedures including crew resource management (CRM); CRM to include hazard identification and crew alerting procedures; Identification of fatigue in the workplace; Re-currency training if appropriate.

26 Feb 2002 Electricity Supply Association of Australia 27 Apr 2002
Received 17 Apr 2002
Monitor
R20010206
The ATSB recommends that Electricity Supply Association of Australia (ESAA) in conjunction with its members and Standards Australia review the current standard on powerline marking. This review should consider identifying the location of low level flight hazards such as spur junctions on transmission lines by the fixing of markers to give visual warnings to aeroplanes or helicopters approaching from either direction while engaged in power line inspection or maintenance operations.
26 Feb 2002 Electricity Supply Association of Australia 27 Apr 2002
Received 17 Apr 2002
Monitor
R20010207
The ATSB recommends that Electricity Supply Association of Australia (ESAA) in conjunction with its members develop a requirement for employees identified by Electrical Supply Companies as candidates for aerial low level power line inspection duties to undergo medical tests including eye tests. These tests should be of a standard commensurate with their expected duties to be performed as crew.
26 Feb 2002 Electricity Supply Association of Australia 27 Apr 2002
Received 17 Apr 2002
Monitor
R20010230
The ATSB recommends that Rolls Royce Ltd expedite the development, trial and implementation of a suitable engineering solution to prevent the mis-installation of combustion fairings on RB211-524 and RB211-22B engines.
5 Feb 2002 Rolls Royce Ltd 6 Apr 2002
Received at 24 Apr 2002
Monitor
R20010251
The ATSB recommends that the Civil Aviation Safety Authority ensure that all Boeing 717-200 aircraft on the Australian Register are fitted with a flight recorder system that complies with the requirements of all applicable Australian Civil Aviation Orders.
20 Dec 2001 Civil Aviation Safety Authority 18 Feb 2002
received at 28 Feb 2002
Monitor
R20010252
The ATSB recommends that the Civil Aviation Safety Authority review flight recorder start/stop logic for all types in the Australian fleet where a type acceptance certificate has been issued to ensure that the aircraft meets the requirements of the Australian Civil Aviation Orders.
20 Dec 2001 Civil Aviation Safety Authority 18 Feb 2002
Received at 28 Feb 2002
Closed - Not accepted
R20010253
The ATSB recommends that the Civil Aviation Safety Authority ensure that all aircraft entering the Australian Register be subject to appropriate scrutiny to ensure that the aircraft complies with the requirements of the Australian Civil Aviation Regulations and Civil Aviation Orders.
20 Dec 2001 Civil Aviation Safety Authority 18 Feb 2002
Received at 28 Feb 2002
Closed - Accepted
R20010254
The ATSB recommends that the Federal Aviation Administration (Piston Engine Certification Directorate) review the certification requirements of piston engines with respect to the operating conditions under which combustion chamber deposits that may cause preignition are formed.
19 Dec 2001 United States Federal Aviation Administration 17 Feb 2002
Received at 8 May 2002
Monitor
R20010255
The ATSB recommends that the Federal Aviation Administration (Piston Engine Certification Directorate) review the practice during assembly of applying anti-galling compounds to the backs of connecting rod bearing inserts with respect to its effect on the safety margin for engine operation of the bearing insert retention forces achieved.
19 Dec 2001 United States Federal Aviation Administration 17 Feb 2002
received at 8 May 2002
Open
R20010256
The ATSB recommends that Textron Lycoming review the practice during assembly of applying anti-galling compounds to the backs of connecting rod bearing inserts with respect to its effect on the safety margin for engine operation of the bearing insert retention forces achieved during assembly.
19 Dec 2001 Textron Lycoming 17 Feb 2002
No response at 30 Jun 2002
R20010257
The ATSB recommends that the Civil Aviation Safety Authority review the operating and maintenance procedures for high powered piston engines fitted to Australian registered aircraft to ensure adequate management and control of combustion chamber deposits, preignition and detonation.
19 Dec 2001 Civil Aviation Safety Authority 17 Feb 2002
Received at 6 Mar 2002
Monitor
R20010258
The ATSB recommends that the Civil Aviation Safety Authority educate industry on procedures and techniques that may maximise the chances of survival of a ditching event. Part of that education programme should include the development of formal guidance material of the type contained in the UK CAA General Aviation Safety Senses leaflet 21A 'Ditching'.
19 Dec 2001 Civil Aviation Safety Authority 17 Feb 2002
Received at 6 Mar 2002
Monitor
R20020120
The ATSB recommends that the Civil Aviation Safety Authority continue to examine the circumstances of electrical discharge damage to the number-1 bearing of the Pratt and Whitney (Canada) PT6A engine models equipped with certain TRW Lucas starter-generators and develop an appropriate safety assurance strategy to ensure the continuing airworthiness of Australian registered aircraft fitted with similar engine and starter-generator combinations.
12 Jun 2002 Civil Aviation Safety Authority 11 Aug 2002
No response at 30 Jun 2002
R20020121
The ATSB recommends that the United States Federal Aviation Administration examine the circumstances of electrical discharge damage to the number-1 bearing of the Pratt and Whitney (Canada) PT6A engine models equipped with TRW Lucas starter-generators and develop an appropriate safety assurance strategy.
12 Jun 2002 United States Federal Aviation Administration 11 Aug 2002
No response at 30 Jun 2002

Table 27: Summary of Australian Transport Safety Bureau safety advisory notices issued to the aviation industry in 2001-02 [1]

Safety Advisory Notice

Issue Date

Receiving Organisation

SAN20010222
The ATSB advises airlines that Passenger Entertainment Landscape Camera systems have the potential to cause passenger distraction during non-normal and emergency situations. Emergency procedures should ensure that the system is operated in a way that will not divert passengers' attention from instructions given by the flight or cabin crew in such situations.
5 Feb 2002

Federal Aviation Administration

Joint Aviation Authority

SAN20010223
The Civil Aviation Safety Authority note the safety deficiency identified in this report relating to single-engine Cessna aircraft seat stops and, as a matter of some urgency, alert aircraft owners, aircraft maintenance engineers and pilots to the potentially dangerous consequences of using other than the specified seat stops and to the importance of correctly locating those seat stops and ensuring that the seat pin securely engages a locating hole on the rail.
24 Oct 2001 Civil Aviation Safety Authority Response received
12 Dec 2001
SAN 20010224
The Aircraft Owners and Pilots Association of Australia note the safety deficiency identified in this report relating to single-engine Cessna aircraft seat stops and consider communicating through the association's journal the potentially dangerous consequences described in this occurrence.
24 Oct 2002 Aircraft Owners and Pilots Association
SAN20010225
The Australian Licensed Aircraft Engineers Association note the safety deficiency identified in this report relating to singleengine Cessna aircraft seat stops and consider communicating through the association's newsletter the potentially dangerous consequences described in this occurrence.
24 Oct 2001 Australian Licensed Aircraft Engineers Association
SAN20010244
The ATSB alerts all operators in the transport industry, particularly those involved in extended-hours operations, to the possibility of crew members suffering sleep inertia and suggests that operators take steps to mitigate the effects of sleep inertia. The steps should not include subjecting employees to sleep deprivation.
15 Apr 2002 Transport industry
SAN20010245
The ATSB suggests that the Civil Aviation Safety Authority alert all aviation industry operators to the possibility of sleep inertia impairing performance, particularly that of flight and maintenance crews.
15 Apr 2002 Civil Aviation Safety Authority Response received
14 May 2002
SAN20020035
The ATSB suggests that the Civil Aviation Safety Authority ensure that operators have strategies in place to mitigate the effects of sleep inertia as part of their fatigue management systems.
15 Apr 2002 Civil Aviation Safety Authority Response received
14 May 2002
SAN20020122
The ATSB suggests that Transport Canada should note the deficiencies identified relating to electrical discharge damage to the number-1 bearing of the Pratt and Whitney (Canada) PT6A engine models equipped with TRW Lucas, model 23078 and 23085, starter-generators.
12 Jun 2002 Transport Canada
SAN20020123
The ATSB suggests that Pratt and Whitney (Canada) should note the deficiencies identified relating to electrical discharge damage to the number-1 bearing of the Pratt and Whitney (Canada) PT6A engine models equipped with TRW Lucas, model 23078 and 23085, starter-generators.

12 Jun 2002 Pratt and Whitney (Canada)
SAN20020124
The ATSB suggests that the United Kingdom Civil Aviation Safety Authority should note the deficiencies relating to electrical discharge damage to the number-1 bearing of the Pratt and Whitney (Canada) PT6A engine models equipped with TRW Lucas, model 23078 and 23085, starter-generators.
12 Jun 2002 United Kingdom Civil Aviation Authority

1. Safety Advisory Notices do not solicit a response, however the Bureau will publish, but will not classify, any response received.

Table 28: Summary of Australian Transport Safety Bureau recommendations issued to the marine industry in 2001 02

Recommendation

Date of issue

  • Independent Investigation into the Grounding of the Kuwaiti Flag Product Tanker Al Deerah, Garden Island
    in the Tamar River, Tasmania on 30 April 2000

The ATSB recommended that the Port of Launceston Authority review the conditions, including tidal conditions,
under which vessels enter and depart the port, consulting as appropriate with the owners and managers of
such vessels.

14 Sept 2001
  • Independent Investigation into the Collision involving the Chinese Bulk Carrier Hai Teng and the Australian Recreational Vessel Chester east of Mooloolaba, Queensland on 19 March 2000

The ATSB recommends that training establishments and authorities issuing certificates of competency, or boating or similar licences, place greater emphasis on training and examining candidates for full knowledge and proper
understanding of the International Regulations for Preventing Collisions at Sea, 1972, as amended and in force
for Australia.

Examinees should be aware of the requirement to maintain the proper lookout on all vessels at all times. In addition, they should be aware that the Collision Regulations do not exonerate any vessel, the owner, master or crew from the consequences of any neglect to comply with the Rules.

The ATSB also recommends that Australian shipowners, managers, pilots and agents take note of Safety Bulletin 02 attached to this report and available on the ATSB website, bringing it to the attention of as many vessels as possible. The bulletin points out that the only explanations for most collisions are the lack of a proper visual lookout, or an over-reliance on radar detection when the radar set has not been correctly set up, or has not been maintained properly.

20 Dec 2001

Table 29: Summary of Australian Transport Safety Bureau recommendations issued to the rail industry in 2001 02

Recommendation

Date of issue to regulator

Target organisation

  • Derailment of Coal Train EG37, Connors Range on 1 July 2001

Review the interface between accident investigation and recovery operations in order that all relevant evidence is collected and/ or recorded in a systematic manner and that potentially safety- critical evidence is not damaged or destroyed as a result of the recovery operation.

26 Oct 2001 Queensland Transport
Queensland Rail
  • Derailment of Coal Train EG37, Connors Range on 1 July 2001

Review the requirement of the two- hour timeframe for the conduct of drug and alcohol tests, as prescribed by the Transport Infrastructure Act 1994, in light of practical constraints that are often posed by the circumstances of rail accidents and incidents.

26 Oct 2001 Queensland Transport
  • Derailment of Coal Train EG37, Connors Range on 1 July 2001

Continue to pursue and address the underlying reason/ s for the extended loss of Locotrol radio communications on the Connors Range as was experienced by EG37. Evaluate whether there may be exposure to similar risks at other locations within the Queensland Rail (QR) network.

Consider the development of threshold limits for both frequency and length of Locotrol radio communication interruptions, in conjunction with requirements for braking in the particular area, as part of an overall strategy to address any unacceptable exposure to risk within the QR network.

Explore options that will allow real- time information about the status of train brake continuity to be communicated to the driver and/ or will provide a driver with other mechanisms or options that result in improved train braking efficiency in abnormal and emergency situations.

A further review of train maintenance practices and procedures, taking into consideration human factors issues, to ensure safety critical systems are subject to more rigorous quality control.

Implement strategies that will reinforce the notion that drivers should operate, as far as is practicable, in accordance with prescribed procedures in order to avoid unnecessary exposure to increased operational risks.

Clarify existing arrangements in relation to Authorised Persons to ensure that those personnel know their rights and obligations and that information about alcohol and drugs as a potential factor in an occurrence is collected in a timely fashion.

Consider an expanded programme for the fitment of Dataloggers, or similar technology, to ELRC units and all locomotives in order to provide safety investigation personnel with additional and timely information about potentially safety- critical issues.

26 Oct 2001 Queensland Rail
  • Collision between Suburban Electric Passenger Train 6369 and the Empty Express Electric Train 6371, Footscray, Victoria 5 June 2001

Medical standards should be reviewed to:

  • better monitor drivers health and ensure a full past history and current medication regime is taken
  • include an appropriate assessment of the current physiological and psychiatric status of all drivers to ensure operators have all relevant information on which to base an informed decision on driver fitness
  • provide a system to monitor self- medication of over- the- counter and non prescription medicine medication
  • include a system to identify drivers at potential risk, with provision for monitoring ongoing fitness
  • ensure that medical examination periods are strictly adhered to and drivers suspended if not holding current medical license
  • include assessment of psychological and psychiatric fitness
  • require drivers to produce proof of medical fitness at any time
  • create an audit system that will allow confirmation of compliance with such standards.
The medical examination procedures should be reviewed to ensure no perception of any conflict of interest may be present in future medical fitness system and whether such examinations should be conducted by a panel of doctors appointed by, and responsible, to the accreditation authority.
Nov 2001 Victorian Department of Infrastructure
  • Collision between Suburban Electric Passenger Train 6369 and the Empty Express Electric Train 6371, Footscray, Victoria 5 June 2001

Australian Standard AS 4292 should be reviewed in respect of the monitoring of the health and fitness of rail safety staff.

Nov 2001 Victorian Department of Infrastructure State/ Territory rail
  • Collision between Suburban Electric Passenger Train 6369 And The Empty Express Electric Train 6371, Footscray, Victoria 5 June 2001

The anti- collision posts on motor cars on Com Eng trains should be investigated to identify any deficiency in their design.

Rail accident response plans should be reviewed to provide procedures to ensure immediate safety of the track infrastructure, training for station staff at manned stations in immediate response procedures and rapid deployment of staff at unmanned stations.

Nov 2001 National Express
  • Collision between Suburban Electric Passenger Train 6369 and the Empty Express Electric Train 6371, Footscray, Victoria 5 June 2001

The signalling system and overlap should be reviewed with a view to ensuring trains passing a signal at danger are stopped within a safe distance. In sections before a station this distance should ensure a train is brought to a halt before a possible collision with another train stopped at the station.

The use of hand and foot pilot valves should be reviewed, given their limitations, to determine whether the system can be made more effective or whether an alternative, equivalent system might make a better safeguard.

The train system radio network should be reassessed for radio reliability.

Nov 2001 Victorian Department of Infrastructure National Express
  • Derailment of Passenger Train 8622, Sydney Melbourne Daylight XPT Service, Wodonga, Victoria 25 April 2001

It is recommended that Australian Rail Track Corporation (ARTC) ensure that the Victorian track under their control meets the requirements of the PTC Civil Engineering Circulars with respect to the number of spring spikes fitted to sleeper plates on curves.

It is recommended that ARTC ensure that the Victorian track under their control has ballast regulated to allow all track fastenings to be effectively inspected.

It is recommended that ARTC track project management practice in future includes effective consultation and communication with line maintenance staff to ensure that contracted track rectification and maintenance activities are properly coordinated and completed.

It is recommended that line maintenance practices in future include sufficient risk assessment to ensure that vulnerable sites are adequately monitored and maintained.

6 Jun 2002 Australian Rail Track Corporation
  • Derailment of Passenger Train 8622, Sydney Melbourne Daylight XPT Service, Wodonga, Victoria 25 April 2001

It is recommended that XPT maintenance practices are reviewed to ensure that their rolling stock in service meets the required standards with regard to wheel flange thickness.

It is recommended that XPT maintenance practices are modified to improve the serviceability of the NHA bogie side bearer friction surfaces and ensure that the design X factor of the bogies is maintained.

6 Jun 2002 New South Wales State Rail
  • Derailment of Passenger Train 8622, Sydney Melbourne Daylight XPT Service, Wodonga, Victoria 25 April 2001

It is recommended that Countrylink implement their Emergency and Evacuation Preparedness Plan as a priority and provide the necessary training for their train crews.

6 Jun 2002 Countrylink