The Caboolture Aero Club did not effectively manage or inform pilots of the risk presented by trees and buildings around the airfield that prevented pilots from being able to see aircraft on intersecting runways and approach paths.
The Civil Aviation Safety Authority guidance for pilots using non-controlled aerodromes did not clearly define the active runway. The guidance did not provide practical advice to pilots using a secondary runway, and in some situations, it was contrary to existing regulations.
Due to topography and buildings at Mildura Airport, aircraft are not directly visible to each other on the threshold of runways 09, 27 and 36. The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.
De Havilland Aircraft of Canada Limited did not publish any guidance to operators of Dash 8 aircraft on the transmission and reception performance limitations of VHF COM 2 radios for ground-based communications.
The QantasLink radio procedure required Dash 8 flight crews to use the VHF COM 2 radio to broadcast and receive on local frequencies during operations at non-controlled aerodromes. This reduced the ground-based radio transmission and reception strength, and therefore reduced the likelihood of other aircraft receiving calls in some circumstances.
Qantas lacked a procedure to assess cabin crew fitness after a serious injury. This increased the risk that a crew member could continue to operate while being unfit for duty.
Esso Australia did not have a procedure for a helicopter recovery from inadvertent IMC during hoist operations or recovery procedures for EGPWS alerts or advisories.
Wave Air's weight and balance system used an incorrect empty weight moment arm to calculate the aircraft's centre of gravity, and passengers were not weighed in accordance with their procedures.
The training, supervision and checking flights conducted by Wave Air did not identify that an excessive approach speed was routinely being used by the pilot during the final approach to land.
The decision height for assessing whether an aircraft met Wave Air’s stabilised approach criteria was too low.
Broome Aviation’s operations manual did not include a procedure for recording inflight fuel calculations. As a result, pilots adopted varying methods for fuel monitoring, leading to reduced assurance of accurate fuel management.
Aircraft defects were not written on the maintenance release, leading to several defects not being rectified or managed.
During the 8-month period from November 2022 until the accident, Broome Aviation provided its pilots transitioning to operating the Cessna 310 with limited supervision, guidance and support, including management of the fuel system.
Broome Aviation pilots experienced pressure not to report aircraft defects on maintenance releases, and many pilots also experienced or observed pressure from individuals within the company management to conduct flights in aircraft with defects that they considered made the aircraft unsafe for flight.
At the time of park pad assessment, the Civil Aviation Safety Authority's guidance documents for establishment of helipads did not prompt assessment of flight path interaction with other already established traffic.
Sea World Helicopters commenced operations with EC130 helicopters without a formal change management process. Implementation of the operator's documented procedures would have increased the likelihood of formal consideration of various risk controls, including controls that were previously applied for the introduction of aircraft.
Sea World Helicopters did not have documented procedures or guidance on the correct fitment of aircraft seatbelts in conjunction with constant wear lifejackets. As a result, on the job training provided to ground crew included incorrect fitting practices, leading to passengers being routinely incorrectly restrained. This increased the risk of injury to passengers in the event of an accident.
Sea World Helicopters' passenger safety briefing system, comprising of a passenger safety briefing video supplemented by safety cards and ground crew advice had limited, inconsistent and incorrect information about correct fitment of seatbelts, location and emergency operation of the EC130 doors, and the emergency brace position.
Reopening the Park Pad in March 2022 created an increased risk of collision with traffic operating from the existing heliport. The conflict point was placed at a location where:
Sea World Helicopters was reliant on CTAF calls, ground crew advice, and pilot visual detection of aircraft to ensure separation in VH-XH9 and VH-XKQ. Available additional controls for enhancing alerted see-and-avoid and reducing the risk of collision were not implemented.
