The Rail Industry Safety and Standards Board did not provide design and/or performance standards on modular cabin resilience and retention for locomotive crashworthiness.
The design of the modular cabin mount was not resilient to frontal impact forces in the event of a collision. This increased the risk of their failure and separation of the cabin, removing the effectiveness of protection afforded by the collision posts.
The procedure for predeparture testing, as part of the coupling procedure, required two competent staff. There was no procedure in the operations manual to ensure that a competent and qualified person was present to assist the driver.
The ATSB recommends that Eastern Air Link address the safety issue, through provision of guidance and training to flight crew concerning the safest option in the selection of an approach method when weather conditions are marginal for the conduct of a visual approach.
The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions.
The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions. Using this approach method, rather than a straight in instrument approach, significantly reduced obstacle clearance assurance for both an approach and any potential missed approaches, and also increased the risk to both the operator’s and other aircraft through the use of a non-standard circuit procedure.
The aircraft system to be used in the event of a main deck cargo smoke event on the operator’s B737 fleet was being routinely used by the operator’s engineering personnel in Darwin as a means to cool the flight deck. This practice had become normalised as a result of the perceived benefit of doing so, but there were insufficient risk controls in place to ensure that the aircraft would be returned to the correct configuration prior to departure.
Recommendations in CASA guidance CAAP 92-1(1) requiring obstacle clearance out to 900 m may lead to circumstances where ALAs meet these requirements however, aircraft are required to manoeuvre below a safe height or be unable to outclimb rising terrain after take-off more than 900 m past the runway end.
The CASA sample operations manual used by the operator that allowed any aerodrome in the Enroute Supplement Australia to be used for flight training did not assure that these aerodromes were suitable for use.
Network Aviation did not include the threat of unforecast weather below landing minima in their controlled flight into terrain risk assessments. This increased the risk that controls required to manage this threat would not be developed, monitored, and reviewed at a management level.
Network Aviation did not provide their flight crew with a diversion decision-making procedure for the circumstances where their flights encountered unforecast weather below landing minima. This increased the risk that their flight crew would not anticipate and be adequately prepared for a diversion.
The illumination of the joystick steering panel’s ‘joystick on’ light indicated which panel was selected (or last selected) for use and bore no relation to the steering mode selected. This increased risk as it was misleading and contrary to the understanding of the ship’s officers who believed that the illumination of the light was only possible when the joystick steering mode was selected.
Neither the master nor the second mate had undertaken required bridge resource management training. This probably contributed to the ineffective implementation of bridge resource management on board, which resulted in the single person errors that contributed to this accident not being detected.
The mitigations introduced by Airbus to counter the design limitation associated with the A330 cabin pressure control systems were ineffective, because:
Response by Airbus
The operator’s training system did not adequately cover the unique requirements of the CAB PR EXCESS CAB ALT alert procedure, increasing the risk of an incorrect or delayed application of the required procedure.
The aircraft was not fitted nor required to be fitted with a crash-resistant fuel system under the current standards or those in place at the time of manufacture. As a result, post-impact fire presents a significant risk of fire-related injuries and fatalities to aircraft occupants.
Response by the United States Federal Aviation Administration
The Federal Aviation Administration is forming a cross-organisational team to review the topic of post-crash fires and identify potential risk mitigations.
The DEENA 7 standard instrument departure has no designed positive separation method, making it susceptible to loss of separation occurrences.
The DEENA 7 standard instrument departure has no designed positive separation method, making it susceptible to loss of separation occurrences.
The surveillance flight information service (SFIS) had been implemented in an area with known surveillance coverage limitations, resulting in the SFIS controller having no displayed positional information for the Caravan until it reached an altitude of about 1,500 feet. Therefore, during the period of conflict between the Caravan and B737, the controller was solely reliant on radio communications for situation awareness, reducing their ability to provide appropriate traffic and avoidance advice.
The eTAP system, used at Track Occupancy Authority (TOA) fulfilment, did not include a key safeworking requirement contained in the ARTC Network Rule ANGE 204 for confirming and repeating back safety critical information.
ARTC will undertake a review of the relevant Rules and Procedures applicable to TOA Fulfilment being ANWT 304 and ANPR 701, including ANGE 204.
