The operators recurrent simulator training did not address the recovery from a stall or stick shaker activation such that the ongoing competency of their flight crew was not assured.
The operators procedures did not include a validation check of the landing weight generated by the flight management system which resulted in lack of assurance that the approach and landing speeds were valid.
The presentation on the aircraft load sheet of the zero fuel weight immediately below the operating weight, increased the risk of selecting the inapropriate figure for flight management system data entry.
The current ARTC definition of restricted speed requires considerable judgement on the part of train drivers.
Train drivers receive no formal training with respect to understanding severe weather events, the associated derailment risk and mitigation strategies.
Double stacked container wagons are at particular risk of wind induced roll-over. This is a direct relationship of exposed side area, and was therefore probably exacerbated by out of gauge/high loads on some wagons with a large surface area exposed to the gust front.
The available Cross Crew Qualification and Mixed Fleet Flying guidance did not address how flight crew might form an expectation, or conduct a ‘reasonableness' check, of the speed/weight relationship for their aircraft during takeoff.
The LTN-101 air data inertial reference unit (ADIRU) model had a demonstrated susceptibility to single event effects (SEE). The consideration of SEE during the design process was consistent with industry practice at the time the unit was developed, and the overall fault rates of the ADIRU were within the relevant design objectives.
Patrick Terminals’ safe work instructions for lashing/unlashing did not specifically cover the recognised safe practices of not working under containers or between moving containers and fixed objects. Consequently, there was a discontinuity between the level of awareness regarding these dangers and the training new employees received during their induction period.
Although passengers are routinely advised after takeoff to wear their seat belts when seated, this advice typically does not reinforce how the seat belts should be worn.
There was a limitation in the algorithm used by the A330/A340 flight control primary computers (FCPCs) for processing angle of attack (AOA) data. This limitation meant that, in a very specific situation, multiple spikes in AOA from only one of the three ADIRUs could result in a nose-down elevator command.
Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.
Although passengers are routinely reminded to keep their seat belts fastened during flight whenever they are seated, a significant number of passengers have not followed this advice. At the time of the first in-flight upset, more than 60 of the 303 passengers were seated without their seat belts fastened.
In recent years there have been developments in guidance materials for system development processes and research into new approaches for system safety assessments. However, there has been limited research that has systematically evaluated how design engineers and safety analysts conduct their evaluations of systems, and how the design of their tasks, tools, training and guidance material can be improved so that the likelihood of design errors is minimised.
Patrick Terminals had no formalised policy in place to provide clear guidance to its stevedoring employees about where they could or could not work on a ship when cargo was being loaded or discharged.
Patrick Terminals’ risk assessment process for lashing and unlashing operations had not anticipated a fatal accident resulting from being struck by items falling from a portainer or cargo, or from being struck by a moving container. As a result, while the appropriate risk control for this occurrence had been covered during employee training, this was not reinforced in safe work instructions, an important risk control measure.
There has been very little research conducted into the factors influencing passengers’ use of seat belts when the seat-belt sign is not illuminated, and the effectiveness of different techniques to increase the use of seat belts.
The recognised safe practices of not working under or near a container being loaded is not well reflected in national and international guidance published to assist container terminal operators develop their own safety policies and guidelines.
When developing the A330/A340 flight control primary computer software in the early 1990s, the aircraft manufacturer’s system safety assessment and other development processes did not fully consider the potential effects of frequent spikes in the data from an air data inertial reference unit.
