The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude (specifically above flight level 200).
The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle.
Although CHC Helicopter Australia’s operations manual stated that emergency medical service flights should be conducted under instrument flight rules (IFR) ‘where practical’, its procedures for night visual flight rules (NVFR) operations using night vision goggles did not clearly state when IFR rather than NVFR should be used.
Although the operator had procedures for conducting a verbal safety briefing prior to flight and had safety briefing cards available, its risk controls did not provide assurance that all passengers would understand the required procedures for emergency landings. More specifically:
The Bureau of Meteorology did not have a procedure to ensure that a recording of the local weather forecast for balloon operations in the Melbourne area was correctly uploaded and accessible to balloon pilots.
The engine manufacturer did not have specific inspection procedures in the maintenance documents of the propeller shaft to detect a fatigue crack originating from the dowel pin hole.
Civil Aviation Order 20.7.1B stipulated that a 1.15 (15 per cent) safety margin was to be applied to the actual landing distance for jet-engine aircraft with a maximum take-off weight greater than 5,700 kg. This safety margin may be inadequate under certain runway conditions, which increases the risk of a runway excursion. The corresponding guidance in Civil Aviation Advisory Publication 235-5(0) had not been updated to account for this.
Virgin Australia Airlines/Virgin Australia International did not have a policy requiring crews to independently cross-check environmental information and landing performance calculations in-flight, removing an opportunity to detect crew errors.
There was no regulatory direction from the Civil Aviation Safety Authority on how a damp runway was to be considered for aircraft landing performance.
Several months prior to the incident, Virgin Australia Airlines/Virgin Australia International changed their policy on calculating landing performance for damp runways from referencing a wet runway to a dry runway.
The hazard associated with the inability to separate aircraft that are below the appropriate lowest safe altitude at night was identified but not adequately mitigated. This resulted in a situation where, in the event of a simultaneous go-around at night during land and hold short operations at Melbourne Airport, there was no safe option available to air traffic controllers to establish a separation standard when aircraft were below minimum vector altitude.
The current legislation does not require commercial operators of aircraft not greater than 5,700 kg maximum take-off weight to provide instructions and procedures for crosschecking the quantity of fuel on board before and/or during flight. This increases the risk that operators in this category will not implement effective fuel policies and training to prevent fuel exhaustion events.
The Australian Transport Safety Bureau advises helicopter operators involved in overwater operations of the importance of undertaking regular HUET (helicopter underwater escape training) for all crew and regular passengers to increase their survivability in the event of an in-water accident or ditching.
Safety Advisory Notice for all helicopter operators engaged in overwater operations
The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.
The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.
The operator commenced regular public transport operations into Kosrae with the only instrument approach available for use being an offset procedure based on a non-precision navigation aid. The risk associated with this type of approach was amplified due to the need to use a 'dive and drive' style technique instead of a stable approach path, and that it required low level circling manoeuvring from the instrument approach to align the aircraft with the runway.
The operator's documented procedure for company personnel to report accidents and incidents was in itself not sufficient to ensure that occurrences that had affected, or had the potential to affect safety, were reported to management. This decreased the opportunity for the operator to identify potential operational risks and take appropriate action to minimise them.
Guidance material associated with the FAID bio-mathematical model of fatigue did not provide information about the limitations of the model when applied to roster patterns involving minimal duty time or work in the previous 7 days.
Consistent with widely-agreed safety science principles, the Civil Aviation Safety Authority’s approach to surveillance of larger charter operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the actual conduct of line operations (or ‘process in practice’).
The Civil Aviation Safety Authority’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.
