Many of the existing civil helicopter fleet are not fitted with a crash-resistant fuel system, or do not have an equivalent level of safety associated with post-impact fire prevention.
Although certification requirements for helicopters to include a crash-resistant fuel system (CRFS) were introduced in 1994, several helicopter types certified before these requirements became applicable are still being manufactured without a CRFS.
Controllers were routinely exposed to ‘not concerned’ radar tracks that were generally inconsequential in the en route environment, leading to a high level of expectancy that such tracks were not relevant for aircraft separation purposes. Training did not emphasise the importance of scanning ‘not concerned’ radar tracks in jurisdiction airspace.
The limited interoperability between The Australian Advanced Air Traffic System and Australian Defence Air Traffic System increased the risk of error due to the need for a number of manual interventions or processes to facilitate the coordination and processing of traffic.
There was a significant underreporting by Virgin Australia Regional Airlines Pty Ltd ATR72 terrain awareness warning system-related occurrences.
The convergence of many published air routes overhead Adelaide, combined with the convergence point being positioned on the sector boundary of the Augusta and Tailem Bend sectors, reduced the separation assurance provided by strategically separated one-way air routes and increased the potential requirement for controller intervention to assure separation.
All-engine go-arounds in modern air transport aircraft are often a challenging task when there is a requirement to level-off at a low altitude, and many pilots have had limited preparation for this task.
The company’s Required Navigation Performance approach procedure allowed the flight crew to set the approach minimum altitude in the auto-flight system prior to commencing the approach. This did not ensure the altitude alerting system reflected the assigned altitude limit of 7,000 ft and removed the defence of that alert when the flight crew did not identify the disengagement of the flight management computer-derived VNAV PTH mode.
The Department of Defence’s risk assessment and review processes for the implementation of the Comsoft Aeronautical Data Access System and removal of the flight data position did not effectively identify or manage the risks associated with the resulting increased workload in the Darwin Approach environment, in particular with regard to the Planner position.
The Department of Defence had not provided Darwin-based controllers with regular practical refresher training in identifying and responding to compromised separation scenarios.
The Darwin Approach long-range display was a low resolution screen that presented air traffic control system information with reduced clarity and resulted in it having diminished effectiveness as a situation awareness tool.
Darwin Approach controllers were routinely exposed to green (limited data block) radar returns that were generally inconsequential in that Approach control environment, leading to a high level of expectancy that such tracks were not relevant for aircraft separation purposes. Refresher training did not emphasise the importance of scanning the green radar returns.
The Australian Defence Air Traffic System (ADATS) did not automatically process all system messages generated by The Australian Advanced Air Traffic System. In cases where transponder code changes were not automatically processed, the risk controls in place were not able to effectively ensure that the changes were identified and manually processed.
The proximity of the landing gear selector valve electrical wiring loom to the external hydraulic power connectors within the left engine nacelle on Fairchild SA227-AT Metro aircraft resulted in the ‘down selection’ wire being damaged during routine maintenance activities.
Although the operator’s rostering practices were consistent with the existing regulatory requirements, it had limited processes in place to proactively manage its flight crew rosters and ensure that fatigue risk due to restricted sleep was effectively minimised.
Jabiru engines manufactured before July 2011 have reduced strength and reliability of the crankshaft/propeller flange joint, compared with the later design that incorporated positive location dowel pins.
The engine manufacturer’s documents with respect to the propeller mounting flange were technically inconsistent with regard to painting and torqueing procedures.
The manufacturer’s specified procedure for assembling and torqueing of the crankshaft/propeller flange fasteners was ineffective in ensuring resistance against subsequent joint movement in service.
The training provided to the pilot did not afford him the opportunity to develop the competencies required to exercise the privileges of the Recreational Aviation Australia Incorporated private pilot certificate.
The approach to the management of risk at the Old Bar Beach Festival, particularly specifically in relation to aviation activities, was ineffective and resulted in a high level of unmanaged risk that had the potential to impact on the objectives of the festival.
