The ATSB found the common practice of approaching safety critical zones at higher speed likely affects multiple rail operators and can increase the risk of accidents such as derailment due to limitations in operating systems.
Bearing failures leading to derailment continue to occur within the Australian rail network. Rail operators must continue to be vigilant and ensure axle bearings are correctly installed, maintained, and monitored throughout their life.
Pre-flight planning needs to include consideration of not only the conditions on departure, but at all stages of the flight. This informs the decision of whether to depart and allows for prior consideration of alternative actions in the case of deteriorating weather, such as returning or diverting.
A number of safety issues were also identified by the ATSB. These included findings associated with occupant restraint, modification of parachuting aircraft and the regulatory classification of parachuting operations.
The ATSB found that the additional instructions attached to the train order distracted the crew from their principal task, which was to stop at the 48 km location. The ATSB also found that there were no visual cues to alert train crew that they were approaching the limit of their authority.
Approximately 4 hours into the flight, just north of Australia, the airspeed indications became erratic. As a result, the autopilot disconnected and the Primary Flight Control reverted to a mode with fewer automated functions and protections.