The administrative controls used by ARTC to warn train crew about temporary speed restrictions were vulnerable to errors in creation and communication. There were opportunities to improve the effectiveness of existing controls and adopt technology‑supported solutions.
The Manual of Air Traffic Services did not explicitly state that sequencing instructions were required to be read back by a pilot, providing no assurance that this safety-critical aspect had been correctly understood.
Pearl Coast Helicopters did not formally manage risk in the context of its primary business which was multiple helicopter mustering operations.
Pearl Coast Helicopters did not establish appropriate separation standards for its helicopters or provide documented procedures to ensure pilots established and maintained appropriate separation.
Spirit of Tasmania I’s safety management system procedure for Job Safety Analyses (JSA) was not effectively implemented. As a result, the JSA required for replacing the main engine turbocharger bearing housing cover plate was not in place. In addition, JSAs covering other work on top of the engine did not address the risks involved in accessing the work site.
The Civil Aviation Safety Regulations Part 139 Manual of Standards did not recommend or provide standardised options for movement area guidance signs or other visual aids to draw flight crew attention to the start of take-off position, especially those distant from a displaced threshold and not coincident with a taxiway/runway intersection.
The ship’s safety management system did not have adequate controls to manage the risk of a complete power failure due to generators being inadvertently left in manual mode during manoeuvring operations.
The Australian Airline Pilot Academy flying school flight crew operation manual only required pilots to select ALT on the transponder, as part of the Pre Line Up Scan Action Flow and associated Checklist prior to entering the runway. The use of a transponder during taxi would normally provide an additional source of positional data to other pilots, aiding visual identification and alerted 'see‑and‑avoid' to other aircraft.
QantasLink's radio procedure required crew to use communications panel radio 2 (COM 2) to broadcast and receive on local frequencies during operations at a non‑controlled aerodrome. This reduced the likelihood of the Dash 8 receiving the calls from other aircraft at either end of runway 05/23 at Wagga Wagga in certain circumstances.
Malaysia Airlines did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety.
Bamboo Airways did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety.
The International Civil Aviation Organization (ICAO) Annex 11 requirement for flight crews to confirm automatic terminal information service (ATIS) identifier with air traffic control did not provide positive assurance that crews had received the information in full, which included essential information on aerodrome conditions, and there were no standard air traffic control communication procedures for providing this assurance.
The Australian Aeronautical Information Publication requirement for flight crews to confirm automatic terminal information service (ATIS) identifier with air traffic control did not provide positive assurance that crews had received the information in full, which included essential information on aerodrome conditions, and there were no standard air traffic control communication procedures for providing this assurance.
The International Civil Aviation Organization (ICAO) Annex 14 standards and recommended practices did not recommend, or provide standardised options for, movement area guidance signs or other visual aids to provide enhanced flight crew situational awareness of temporary changes to the runway length available for take-off.
The Part 139 (Aerodromes) Manual of Standards 2019 did not recommend, or provide standardised options for, movement area guidance signs or other visual aids to provide enhanced flight crew situational awareness of temporary changes to the runway length available for take-off.
A number of the risk controls established by Fremantle Ports to ensure the safe entry of large container vessels were ineffective. These included:
AirMed required pilots to apply an incorrect landing distance factor, which reduced the safety margin when determining the required landing distance at a destination aerodrome. Furthermore, its procedures were unclear on how the factor should be applied, when the assessment should be conducted and how runway surface condition should be considered.
The type rating training provided by Air Link taught pilots to apply an incorrect landing distance factor, which reduced the safety margin when determining the required landing distance at a destination aerodrome.
On board the Wisdom Venture, a permanent modification to the steam drain line was implemented without documentation. During the modification process, change was not incorporated into a risk assessment and no formal review was conducted. This undocumented change likely introduced a system vulnerability that undermined the effectiveness of the steam system isolation.
Response by master of Wisdom Venture and ship manager
A modification to the cargo heating main steam system drain line was not identified during multiple company superintendent’s visits. This resulted in the Wah Kwong Ship Management (Hong Kong) management of change framework, which required that any system modifications be subject to formal risk assessment and documentation, not being effectively applied.
Response by Wah Kwong Ship Management (Hong Kong)
