At the time of the occurrence, the approved QantasLink training did not provide first officers with sufficient familiarity on the use of the oxygen mask and smoke goggles. This likely contributed to the crew's communication difficulties, including with air traffic control.
Airservices Australia did not provide procedures with associated local instructions to Melbourne air traffic controllers regarding how to coordinate runway changes at Melbourne Airport. Furthermore, an absence of system tools increased the risk of the controllers forgetting to coordinate those changes with the Essendon Aerodrome Controller.
Compromised separation recovery training deficiencies existed within the Department of Defence at the time of the occurrence, increasing the risk of inappropriate management of aircraft in close proximity.
In‑flight opening of the tip-up canopy in a number of Van’s Aircraft Inc. models has resulted in varying consequences, including a significant pitch down tendency, increasing the risk of a loss of control.
The procedures provided to ground and flight crews by Malaysia Airlines Berhad and the towbarless tractor operator did not provide clear guidance or instruction on coordinating activities related to pushback and, in the case of the tractor operator, were informally replaced by local procedures
The Citation aircraft did not have an annunciator light to show that the parking brake is engaged, and the manufacturer’s before take-off checklist did not include a check to ensure the parking brake is disengaged.
Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.
For many non‑major airports in Australia, flight crews of arriving aircraft can access current weather information using an Automatic Weather Information Service via very high frequency radio, which has range limitations. Where this service is available, air traffic services will generally not alert pilots to significant deteriorations in current weather conditions at such airports, increasing the risk of pilots not being aware of the changes at an appropriate time to support their decision making.
Airservices Australia had not provided en route air traffic controllers with effective simulator-based refresher training in identifying and responding to compromised separation scenarios, at intervals appropriate to ensure that controllers maintained effective practical skills.
The utilisation of shift sharing practices for the Tops controllers resulted in them sustaining a higher workload over extended periods without a break, during a time of day known to reduce performance capability.
The relevant tasks in the trouble shooting manual did not specifically identify the pitot probe as a potential source of airspeed indication failure.
The Civil Aviation Safety Authority did not require builders of amateur‑built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. Without a flight manual the builder, other pilots and subsequent owners do not have reference to operational and performance data necessary to safely operate the aircraft.
The maintenance program for the aircraft’s landing gear did not adequately provide for the detection of corrosion and cracking in the yoke lug bore.
The engineering justification supporting Australian supplemental type certificate SVA521 did not contain consideration of the effect an increase in the average operating speed could have on the rate of fatigue damage accumulation.
Important information relating to Civil Aviation Safety Authority (CASA) airworthiness directive AD/PZL/5 was not contained in CASA’s airworthiness directive file, but on other CASA files with no cross-referencing between those files. This impacted CASA’s future ability to reliably discover that information and make appropriately‑informed decisions regarding the airworthiness directive.
The documented procedure for eddy current inspection of M18 wing attachment fittings did not assure repeatable, reliable inspections.
Operation of M18 aircraft with a more severe flight load spectrum results in greater fatigue damage than anticipated by the manufacturer when determining the service life of the M18. If not properly accounted for, the existing service life limit, and particular inspection intervals, may not provide the intended level of safety.
Although wing removal was necessary to provide adequate access for effective visual and magnetic particle inspections of M18 wing attachment fittings, the aircraft manufacturer’s service bulletin E/02.170/2000 allowed the wings to remain attached during these inspections.
The Civil Aviation Safety Authority did not have a defined process for a robust, systematic approach to the assessment and approval of alternative non-destructive inspection procedures to ensure that the proposed method provided an equivalent, or better, level of safety than the original procedure.
