Although the Director of National Parks’ safe operating procedures required shooters and spotters to wear helmets during aerial culling tasks, helmets were not provided or used on a routine basis.
Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in important safety issues not being identified, which may remain a hazard to current and future passenger carrying operations.
There was no regulatory requirement from the Civil Aviation Safety Authority for piston‑engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin.
Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non‑identification of safety issues, which continue to present a hazard to current and future passenger-carrying operations.
Response by the Civil Aviation Safety Authority
Although detectors were not required to be fitted to their aircraft, Sydney Seaplanes had no mechanism for monitoring the serviceability of the carbon monoxide detectors.
While the manufacturer's instructions for the zonal inspections detailed that installation blankets could be removed 'as necessary', they did not reference the insulation blanket installation procedure. This resulted in insulation blankets not being secured to the structure.
Pacific National’s inspection processes did not identify key structural points for inspection on RRYY class wagons, including the susceptibility to cracking in the junction between container loading outriggers, pull rod boxed opening, and the bottom centre sill sections. This reduced the likelihood of cracks being detected.
Pratt & Whitney Canada (PWC) PT6A-114A engines fitted with compressor turbine vane rings that have been repaired in accordance with the United States Federal Aviation Administration‑approved scheme STI 72-50-254 have a significantly increased likelihood of CMSX-6 compressor turbine blade fracture and subsequent failure of the engine compared to those engines fitted with PWC‑manufactured compressor turbine vane rings.
The ARTC systems for managing track lateral stability did not lead to the location being managed as a location potentially vulnerable to instability.
Response by Australian Rail Track Corporation (ARTC)
Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.
Virgin Australia Airlines did not require ATR flight crews to complete the Before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying was critical.
Pacific National's Freight Loading Manual did not require the use of radial unitising straps to prevent telescoping on jumbo coils where the thickness of the steel was greater than 2 mm.
Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose.
Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of strap breakage due to contact with the cradle.
Pacific National's Freight Loading Manual, specific to the loading and unitising of jumbo coils, did not require the use of rubber load mat on cradles. Consequently, there was no requirement to consider the condition of load mat during inspection and maintenance. This allowed the continued use of cradles without load mat, which decreased their effectiveness at restraining loads.
Neither Alstom’s validation processes nor fault monitoring processes were sufficient to detect the overcharging of batteries prior to the event.
Inspection records for the December 2010 wheelset maintenance activity and wheel change on wheelset number 7E5S 831444 were not available. It is a requirement specified in Pacific National's Wagon Maintenance Manual that records be retained for a period of 12 years.
Axle testing on wheelset number 7E5S 831444 was not carried out during the two most recent wheelset maintenance events in January 2016 and November 2016. It is likely the axle crack existed at the time of these maintenance activities.
Elements of the safety and environment management system are reliant on procedures being followed to manage safety risks. There is little scope for the system to recover when there has been a human error or other procedural error.
The system of placing protection flags on both ends of a train set does not provide a positive isolation of energy to ensure a train cannot be moved while it is being worked on.
