Batik Air's change management processes were not effective at fully identifying and mitigating the risks associated with the commencement of the Denpasar to Canberra route.
Batik Air did not ensure that flight crew completed all common traffic advisory frequency (CTAF) training prior to them operating flights into Australia where the use of these procedures could be required.
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 Caboolture Gliding Club had a regular practice of using runway 06 for some flights, including during periods of light traffic on runway 11/29. This increased the risk of collision as Caboolture was a non-controlled aerodrome relying on alerted see-and-avoid principles, and there was a stand of trees obstructing pilots' vision of intersecting runways.
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.
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.
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.
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.
Port Authority of New South Wales procedures to comply with its Port Safety Operating Licence and the NSW Coastal Waters Marine Pollution Plan were not effectively implemented. This resulted in delays to the required notifications and incident response, which contributed to prolonging the emergency.
Portland Bay’s manager, Pacific Basin Shipping, did not provide the master advice about notifying authorities as per the ship’s safety management system emergency procedures, instead focusing on the engineering matters. This probably led to the master delaying the notification and the request for tug assistance.
The Australian Maritime Safety Authority’s Maritime Assistance Services procedures to support the National Plan for Maritime Environmental Emergencies (National Plan) were not effectively implemented. Consequently, there was a 12-hour delay in tasking the state’s nominated emergency towage vessel, Svitzer Glenrock, which significantly prolonged the emergency.
The Australian Maritime Safety Authority had not adequately managed the National Plan and annual exercises required to prepare for such incidents had not been conducted for 4 years before the incident. This probably resulted in the ineffective implementation of its Maritime Assistance Services procedures, the inefficient process for issuing directions and inadequate coordination of the incident with state authorities.
The Port Authority of New South Wales did not have a proper and correct understanding of its responsibilities for emergency response under its operating licence and relevant state plans. This contributed to the inadequate coordination of emergency towage, salvage and refuge, which were critical for the single, integrated and comprehensive response required and significantly prolonged the emergency.
United Salvage was severely limited in its ability to provide the required salvage services as it did not own, operate or directly control any towage vessels for which it relied on towage providers. This limitation was not made clearly known to Portland Bay’s master, owners or managers or involved authorities to allow them to properly assess whether the most suitable towage vessels, including the emergency towage vessel, had also been promptly deployed for salvage and emergency response.
Response by United Salvage
The Australian Maritime Safety Authority’s process to issue directions was inefficient and resulted in excessive time to issue directions allowing Portland Bay to enter Port Botany as a place of refuge. While this delay did not further prolong the emergency, such delays increase risk in time‑critical situations.
The Australian Maritime Safety Authority, with direct control of key national emergency response arrangements, did not have the required understanding of its central role in any response, regardless of location. Consequently, its support to, and coordination with, the control agency in relation to emergency towage, salvage and refuge was inadequate, inconsistent with National Plan principles of a single, integrated and comprehensive response and significantly prolonged the emergency.
Transport for NSW (NSW Maritime), as the statutory agency responsible for ensuring that New South Wales was prepared to respond to an incident in accordance with the state’s plan that it maintained, had not effectively met this obligation. This resulted in the long delay in New South Wales assuming control of the incident and contributed to the inadequate coordination of the emergency response required for a single, integrated and comprehensive response and significantly prolonged the emergency.
The decision height for assessing whether an aircraft met Wave Air’s stabilised approach criteria was too low.
