Moorabbin GAAP airspace design did not assure lateral or vertical strategic separation between traffic flows. This increased the risk of a mid-air collision.
There was no evidence of any action taken by Airservices to address safety recommendations related to a review of Key Performance Indicators (KPI’s) of GAAP operations.
The aircraft operator did not provide procedures that allowed ground handling personnel to communicate effectively with the flight crew in the event of an urgent operational matter occurring after pushback.
There was no procedure or guidance for the segregation of freight that was rejected during loading.
The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual , with the result that the pilot’s competence and ultimately, safety of the operation could not be assured.
The helicopter landing area was occasionally subjected to rapidly-moving fog or low cloud that increased the risk of flights under the visual flight rules encountering instrument meteorological conditions.
Installation of new cargo door seals resulted in the cargo door being held outside of the flushness requirement specified in the aircraft maintenance manual
The limited consideration of the potential wind impact of the two buildings to the north of runway 12 during northerly wind conditions has resulted in continued operations to that runway in those conditions without any alert to affected pilots about the associated risk.
Two buildings were constructed north of the runway 12 threshold at a height and position that could generate turbulence affecting the approach, threshold and touchdown areas of the runway under some wind conditions.
There were no criteria for assessing the potential wind impact of aerodrome building developments on aircraft operations.
The operator did not have procedures to assist the crew to ensure that the aircraft was lined up on the runway centreline in preparation for takeoff.
When revising or maintaining its A320 endorsement training program, the third party training provider did not use or have access to current versions of the aircraft manufacturer’s recommended training program.
By the time of the 28 October 2009 occurrence, many of the operator’s A330 flight crew had not received unreliable airspeed training. Such training started being introduced in the operator’s recurrent training program before the occurrence.
Although the pitot probes fitted to A330/A340 aircraft met relevant design specifications, these specifications were not sufficient to prevent the probes from being obstructed with ice during some types of environmental conditions that the aircraft could encounter.
At the time of the last tyre change, crack initiation at the bearing bore shoulder radius was an emerging issue with no requirement for mandatory inspection of this area during a tyre change.
The operator’s winching procedure did not include the requirement to confirm adequate hover reference existed overhead an intended winch area prior to deploying personnel on the winch.
There was no formal risk assessment process in use at the operator’s Horn Island base.
The post-2005 main landing gear wheel design had shown a susceptibility to fatigue cracking at the inner hub bearing bore shoulder radius.
Information contained in the approved flight manual and pilot's operating handbook was not applicable to the engine that was fitted to the aircraft.
There was the potential for the incorrect use of the dipstick to result in the over-reading of the fuel quantity.
