The crew of V938 detrained passengers onto the track near Kilbride without having arranged the required train protection with the ARTC Network Controller in accordance with the ARTC Network rules and procedures.
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.
Although the Civil Aviation Safety Authority (CASA) collected or had access to many types of information about a charter and/or aerial work operator, the information was not integrated to form a useful operations or safety profile of the operator. In addition, CASA’s processes for obtaining information on the nature and extent of an operator’s operations were limited and informal. These limitations reduced its ability to effectively prioritise surveillance activities.
Although air ambulance flights involved transporting passengers, in Australia they were classified as ‘aerial work’ rather than ‘charter’. Consequently, they were subject to a lower level of regulatory requirements than other passenger-transport operations (including requirements for fuel planning flights to remote islands).
The available regulatory guidance on in-flight fuel management and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert.
Although passenger-carrying charter flights to Australian remote islands were required to carry alternate fuel, there were no explicit fuel planning requirements for other types of other passenger-carrying flights to remote islands. There were also no explicit Australian regulatory requirements for fuel planning of flights to isolated aerodromes. In addition, Australia generally had less conservative requirements than other countries regarding when a flight could be conducted without an alternate aerodrome.
The operator had not formally defined the roles and responsibilities of key positions involved in monitoring and managing flight operations, such as the standards manager for each fleet and the General Manager Flying Operations (Medivac and Charter).
Although the operator’s safety management processes were improving, its processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations.
Although the operator installed an enhanced ground proximity warning system (EGPWS) and traffic alert and collision avoidance system (TCAS) on VH-NGA in August 2009, it did not provide relevant flight crew with formal training on using these systems, or incorporate relevant changes into the aircraft’s emergency procedures checklists.
The operator’s application of its fatigue risk management system overemphasised the importance of scores obtained from a bio-mathematical model of fatigue (BMMF), and it did not have the appropriate expertise to understand the limitations and assumptions associated with the model. Overall, the operator did not have sufficient risk controls in addition to the BMMF to manage the duration and timing of duty, rest and standby periods.
Although the operator provided its flight crew with basic awareness training in crew resource management (CRM), it was limited in nature and did not ensure flight crew were provided with sufficient case studies and practical experience in applying relevant CRM techniques.
The operator’s risk controls did not provide assurance that the occupants on an air ambulance aircraft would be able to effectively respond in the event of a ditching or similar emergency. Specific examples included:
The operator and air ambulance provider did not have a structured process in place to conduct pre-flight risk assessments for air ambulance tasks, nor was there any regulatory requirement for such a process.
The operator’s risk controls did not provide assurance that the operator’s Westwind pilots would conduct adequate in-flight fuel management and related activities during flights to remote islands or isolated aerodromes. Limitations included:
The operator’s Westwind pilots generally used a conservative approach to fuel planning, and the operator placed no restrictions on the amount of fuel that pilots uploaded. However, the operator’s risk controls did not provide assurance that there would be sufficient fuel on board flights to remote islands or isolated aerodromes. Limitations included:
Bow Singapore’s planned maintenance system for the steering gear did not include or contain any schedules for detailed inspections or parts replacement.
While there has been significant enhancements in the tracking of commercial aircraft in recent years there are some limitations to the improvements. The ICAO mandated 15-minute position tracking interval for existing aircraft may not reduce a potential search area enough to ensure that survivors and wreckage are located within a reasonable timeframe.
There is relatively limited public and official information available about the process and outcomes of some searches. It is not an explicit part of the ICAO Annex 13 guidelines for inclusion in an accident investigation report. Similarly there is no Annex 12 requirement to publish or analyse search information. This limits the ability for researchers to determine the factors that help or hinder a search.
