Neither the New South Wales Rural Fire Service or Queensland Fire and Emergency Service had established cross-border coordination procedures for aerial firefighting activities to ensure reliable aircraft communication and separation.
The New South Wales Rural Fire Service did not have a procedure for ensuring that when large air tankers were dispatched by the state air desk their tasking was coordinated with the incident management team and integrated into the existing incident plan.
The New South Wales Rural Fire Service had no procedure to ensure that fire common traffic advisory frequencies (Fire-CTAFs) were reliably known by state air desk personnel. This resulted in aircraft being dispatched with incomplete Fire-CTAF information.
The New South Wales Rural Fire Services procedures required an air attack supervisor (AAS) when 3 or more aircraft were deployed to a fireground. However, there was:
There was an inconsistent understanding within New South Wales Rural Fire Service state air desk of the threshold required to action task rejection procedures. Consequently, reports of unsafe conditions on the fireground were not promptly actioned.
The New South Wales Rural Fire Service did not have a procedure to implement a temporary restricted area to reduce the risk of an air proximity event with aircraft not associated with firefighting operations.
The New South Wales Rural Fire Service did not have an effective means to manage wake turbulence separation for aircraft operating in the vicinity of the large air tankers, increasing the risk of an unrecoverable loss of aircraft control.
The administrative controls used by ARTC to warn train crew about temporary speed restrictions were vulnerable to errors in creation and communication. There were opportunities to improve the effectiveness of existing controls and adopt technology‑supported solutions.
The Manual of Air Traffic Services did not explicitly state that sequencing instructions were required to be read back by a pilot, providing no assurance that this safety-critical aspect had been correctly understood.
Pearl Coast Helicopters did not establish appropriate separation standards for its helicopters or provide documented procedures to ensure pilots established and maintained appropriate separation.
Pearl Coast Helicopters did not formally manage risk in the context of its primary business which was multiple helicopter mustering operations.
Spirit of Tasmania I’s safety management system procedure for Job Safety Analyses (JSA) was not effectively implemented. As a result, the JSA required for replacing the main engine turbocharger bearing housing cover plate was not in place. In addition, JSAs covering other work on top of the engine did not address the risks involved in accessing the work site.
The Civil Aviation Safety Regulations Part 139 Manual of Standards did not recommend or provide standardised options for movement area guidance signs or other visual aids to draw flight crew attention to the start of take-off position, especially those distant from a displaced threshold and not coincident with a taxiway/runway intersection.
The ship’s safety management system did not have adequate controls to manage the risk of a complete power failure due to generators being inadvertently left in manual mode during manoeuvring operations.
QantasLink's radio procedure required crew to use communications panel radio 2 (COM 2) to broadcast and receive on local frequencies during operations at a non‑controlled aerodrome. This reduced the likelihood of the Dash 8 receiving the calls from other aircraft at either end of runway 05/23 at Wagga Wagga in certain circumstances.
The Australian Airline Pilot Academy flying school flight crew operation manual only required pilots to select ALT on the transponder, as part of the Pre Line Up Scan Action Flow and associated Checklist prior to entering the runway. The use of a transponder during taxi would normally provide an additional source of positional data to other pilots, aiding visual identification and alerted 'see‑and‑avoid' to other aircraft.
Malaysia Airlines did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety.
Bamboo Airways did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety.
The Australian Aeronautical Information Publication requirement for flight crews to confirm automatic terminal information service (ATIS) identifier with air traffic control did not provide positive assurance that crews had received the information in full, which included essential information on aerodrome conditions, and there were no standard air traffic control communication procedures for providing this assurance.
The International Civil Aviation Organization (ICAO) Annex 14 standards and recommended practices did not recommend, or provide standardised options for, movement area guidance signs or other visual aids to provide enhanced flight crew situational awareness of temporary changes to the runway length available for take-off.
