Although a number of aerobatic manoeuvres were permitted in Tiger Moth aircraft, there was no limitation on the amount of aerobatic operations that was considered to be safe. As a result, operators may be unaware that a high aerobatic usage may exceed the original design assumptions for the aircraft.
Together with a number of other Australian Tiger Moths, VH-TSG was fitted with non‑standard Joint H attachment bolts that did not conform to the original design with the result that the integrity of the Joint H could not be assured.
Debris originating from the starter failure was not contained by the starter casing and severed the number one engine B-sump oil scavenge pipe.
The Flight Crew Operating Manual procedure for crew comparison of the calculated Vref40 speed, while designed to assist in identifying a data entry error, could be misinterpreted, thereby negating the effectiveness of the check.
The applicability of a general requirement to conduct aviation risk assessments for complex, new, unusual or irregular activities was open to interpretation.
Unlike other Australian standard arrival routes that included a visual segment, the visual approach to runway 34 at Melbourne via the SHEED waypoint could be issued to super or heavy jet aircraft operated by foreign operators, despite there being more occurrences involving the SHEED waypoint than other comparable approaches.
The LIZZI FIVE RWY 34 VICTOR ARRIVAL required a 3.5° descent profile after passing the SHEED waypoint for visual approach to runway 34 at Melbourne, increasing the risk of an unstable approach.
The Virgin Australia procedures did not require its flight crews to, whenever practicable, announce flight mode changes.
Air traffic control did not, and was not required to provide traffic information to aircraft using adjacent runways and abeam each other during independent visual approach procedures at Sydney.
The presentation of the runway 34 visual approach in the operator's Route and Airport Information Manual increased the risk of the runway threshold crossing altitude being entered into the runway extension waypoint.
Qantas provided limited guidance on the conduct of a visual approach and the associated briefing required to enable the flight crew to have a shared understanding of the intended approach.
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.
Accidents involving Robinson R44 helicopters without bladder-type tanks fitted result in a significantly higher proportion of post-impact fires than for other similar helicopter types. In addition, the existing United States regulatory arrangements are not sufficient to ensure all R44 operators and owners comply with the manufacturer's Service Bulletin SB-78B and fit these tanks to improve resistance to post-impact fuel leaks.
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.
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.
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.
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.
