The balloon manufacturer did not have an adequate process to verify the accuracy of the temperature recorded during production inflation tests.
Regulatory requirements did not ensure that aircraft lighting was adequate to conduct night vision imaging system winching operations safely.
Although the operator’s procedures for winching and night vision imaging system operations included the need to have adequate hover references and a method of recovery in the event of a night vision goggle failure, there was limited guidance to ensure these requirements were confirmed by the flight crew on‑site before commencing precision hover operations.
Toll recency for night vision imaging system (NVIS) winching was insufficient to ensure that complex NVIS winching operations, such as in this occurrence, could be conducted safely.
The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height.
The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions.
The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions. Using this approach method, rather than a straight in instrument approach, significantly reduced obstacle clearance assurance for both an approach and any potential missed approaches, and also increased the risk to both the operator’s and other aircraft through the use of a non-standard circuit procedure.
The aircraft system to be used in the event of a main deck cargo smoke event on the operator’s B737 fleet was being routinely used by the operator’s engineering personnel in Darwin as a means to cool the flight deck. This practice had become normalised as a result of the perceived benefit of doing so, but there were insufficient risk controls in place to ensure that the aircraft would be returned to the correct configuration prior to departure.
Recommendations in CASA guidance CAAP 92-1(1) requiring obstacle clearance out to 900 m may lead to circumstances where ALAs meet these requirements however, aircraft are required to manoeuvre below a safe height or be unable to outclimb rising terrain after take-off more than 900 m past the runway end.
The CASA sample operations manual used by the operator that allowed any aerodrome in the Enroute Supplement Australia to be used for flight training did not assure that these aerodromes were suitable for use.
Network Aviation did not include the threat of unforecast weather below landing minima in their controlled flight into terrain risk assessments. This increased the risk that controls required to manage this threat would not be developed, monitored, and reviewed at a management level.
Network Aviation did not provide their flight crew with a diversion decision-making procedure for the circumstances where their flights encountered unforecast weather below landing minima. This increased the risk that their flight crew would not anticipate and be adequately prepared for a diversion.
The mitigations introduced by Airbus to counter the design limitation associated with the A330 cabin pressure control systems were ineffective, because:
Response by Airbus
The operator’s training system did not adequately cover the unique requirements of the CAB PR EXCESS CAB ALT alert procedure, increasing the risk of an incorrect or delayed application of the required procedure.
The aircraft was not fitted nor required to be fitted with a crash-resistant fuel system under the current standards or those in place at the time of manufacture. As a result, post-impact fire presents a significant risk of fire-related injuries and fatalities to aircraft occupants.
Response by the United States Federal Aviation Administration
The Federal Aviation Administration is forming a cross-organisational team to review the topic of post-crash fires and identify potential risk mitigations.
The DEENA 7 standard instrument departure has no designed positive separation method, making it susceptible to loss of separation occurrences.
The DEENA 7 standard instrument departure has no designed positive separation method, making it susceptible to loss of separation occurrences.
The surveillance flight information service (SFIS) had been implemented in an area with known surveillance coverage limitations, resulting in the SFIS controller having no displayed positional information for the Caravan until it reached an altitude of about 1,500 feet. Therefore, during the period of conflict between the Caravan and B737, the controller was solely reliant on radio communications for situation awareness, reducing their ability to provide appropriate traffic and avoidance advice.
Failure of the inboard programming roller cartridge was due to undetected fatigue cracking that occurred in an area that was not included in the detailed flap actuation system inspection.
Although an applicable height of 1,000 ft for stabilised approach criteria in instrument meteorological conditions has been widely recommended by organisations such as the International Civil Aviation Organization for over 20 years, the Civil Aviation Safety Authority had not provided formal guidance information to Australian operators regarding the content of stabilised approach criteria.
