Qantas's cabin crew recurrent training did not include any situation whereby a disarmed door would have to be rearmed in an emergency. This increased the likelihood that a door would be opened without the escape slide deployed, reducing the number of available exits.
Qantas's cabin crew primary evacuation commands did not include phrases such as 'leave everything behind' and 'jump and slide'; instead, these phrases were optional. Consequently, passengers would generally not receive specific guidance until they reached an exit, which would likely slow down the evacuation.
Qantas’s method of briefing passengers provided limited and inconsistent information about how to use the escape slides safely and what to do with cabin baggage in an emergency.
The sleep log tool used by the operator contained a coding error and it also pre-loaded sleep periods of future nights by default. This combination of factors reduced the likelihood pilots would identify fatigue risks associated with insufficient sleep and extended wakefulness.
The operator's fatigue risk management system relied extensively on a sleep reporting spreadsheet (sleep log) that was based on the prior sleep wake model, and the spreadsheet had a transparent rule set that made the recorded data easy to modify to achieve results that met the operator’s minimum sleep and wake requirements.
The operator’s circuit and approach procedures for marine pilot transfer operations did not minimise pilot workload or provide the recommended stabilised approach criteria with mandatory go-around policy. These procedures could allow a combination of conditions that increased the risk of a sustained abnormal flight path and collision with terrain/water.
The operator's training and assessing procedures for marine pilot transfer operations did not provide assurance that pilot under supervision experience, helicopter instrumentation, and instructor capability were suitable for line training at night in a degraded visual cueing environment.
The instrument panels fitted to VH-ZGA and the operator's other EC135 helicopter at Port Hedland were equipped for single-pilot operation under the instrument flight rules. When used for flight training or checking in a degraded visual cueing environment, this configuration has a detrimental effect on the ability of an instructor or training/check pilot to monitor the helicopter's flight path and take over control if required.
Changes in the operator's key safety post holder positions, safety reporting systems and internal processes reduced effective safety assurance.
The operator’s training for the Fokker F28-Mk0100 did not prepare pilots for alpha mode activation during critical phases of flight.
The operator’s safety management reporting system did not enable the effective prioritisation of submitted safety reports.
The helicopter operator's traffic alert and collision avoidance system knowledge was inadequate with respect to resolution advisory alert terrain considerations and the required intensity of response manoeuvring.
The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height., This delayed the identification and recovery from the unsafe aircraft state resulting in the pilot not identifying the developing rate of descent during the incident, delaying the recovery from the descent.
The En-Route Supplement Australia included a requirement to add 1,000 ft to the prescribed practice instrument approach ‘altitude’ at Mangalore Airport. The procedure did not detail whether this height was to be applied to the minimum descent altitude or to all approach altitudes, resulting in varied application and an increased risk of traffic conflicts. (Safety issue).
Queensland Rail’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes.
Queensland Rail's process for the installation of signal aspect indicators (SAIs) did not provide sufficient detail to ensure consistent and conspicuous placement of SAIs at station platforms. This problem, combined with an SAI’s non-salient indication when the platform departure signal displayed a stop indication, increased the risk that an SAI would not be correctly perceived by a train guard.
Limitations in Queensland Rail’s application of risk management and change management processes relevant to the introduction of the new generation rollingstock (NGR) increased the risk of a start against signal SPAD (signals passed at danger).
The Civil Aviation Safety Authority review of the airspace surrounding Ballina Byron Gateway Airport did not include data for aircraft transiting the airspace without using the airport. Therefore, the risk associated with occurrences such as this one were not specifically considered when assessing the appropriate airspace classification.
BHP's fatigue management processes required its train drivers to be rostered on 7 12-hour shifts, followed by a 24-hour break and then 7 12-hour shifts, with the roster pattern commencing at a wide variety of times of day. Such roster patterns were conducive to result in cumulative sleep restriction and levels of fatigue likely to adversely influence performance on a significant proportion of occasions, and BHP had limited processes in place to ensure that drivers actually obtained sufficient sleep when working these roster patterns.
The automatic train protection (ATP) and electronically controlled pneumatic braking (ECPB) systems on BHP’s trains could not interface to dump brake pipe pressure if an ECPB emergency or penalty brake application became ineffective in arresting an uncommanded train movement.
