The limited consideration of the potential wind impact of the two buildings to the north of runway 12 during northerly wind conditions has resulted in continued operations to that runway in those conditions without any alert to affected pilots about the associated risk.
The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG) that could enhance the administration of the PNG aviation medical regime.
The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
The lack of a reliable mandatory occurrence reporting arrangement minimised the likelihood of an informed response to Papua New Guinea specific safety risks.
The oiler’s actions indicate that he was not aware of the dangers associated with the use of an angle grinder to remove the top of the drum.
The oiler’s actions indicate that he was likely not aware of the ship’s safety management system hot work permit requirements.
The Microlok signalling program design does not meet the requirements of ARTC signalling standard SCP23 ‘Design of Microlok Interlockings’ in regard to the logging of internal bits that initiate flashing, pulsing or toggled outputs.
The voltage of signal JE02 was below the ARTC standard for the type of globe installed.
There was no RailCorp instruction that specifically referred to the need for train crew to prioritise tasks at safety critical locations or at times when workload is high.
The operator did not have procedures to assist the crew to ensure that the aircraft was lined up on the runway centreline in preparation for takeoff.
The ammonium nitrate prills were not packaged in the containers in accordance with the requirements of the IMDG Code. The containers were packed in a way which allowed the prills to move within the container in a way that may have contributed to the failure of the containers and/or the lashing system.
At the time of the incident, there was no requirement for any third party to inspect or survey the fixed and loose lashing equipment on a ship. Had this been done, the maintenance and replacement regime of such equipment on board Pacific Adventurer might have been more effective.
When revising or maintaining its A320 endorsement training program, the third party training provider did not use or have access to current versions of the aircraft manufacturer’s recommended training program.
The poor condition of much of the ship’s container lashing equipment indicates that the inspection and maintenance regime applied to this critical equipment had been inadequate.
Although the pitot probes fitted to A330/A340 aircraft met relevant design specifications, these specifications were not sufficient to prevent the probes from being obstructed with ice during some types of environmental conditions that the aircraft could encounter.
