The Airservices Australia hypoxic pilot emergency checklist did not contain guidance on ceasing the emergency response. This increased the risk that a controller may inappropriately downgrade the emergency response during a developing hypoxic scenario.
AGAIR Gulfstream 690 and 695 aircraft were operated with known defects without being recorded on the aircrafts’ maintenance release, likely as a routine practice. For VH-HPY, the absence of documented historical information limited the ability to assess the operational impact of the pressurisation defect and the effectiveness of maintenance rectification activities.
The AGAIR aircraft VH-HPY pressurisation system could not reliably attain the required cabin altitude during flight due to a known, long-term, unresolved intermittent defect. AGAIR management personnel were aware of the defect and, through a combination of inaction, encouragement and, in some instances direct involvement, permitted the aircraft to continue operations at an excessive cabin altitude.
AGAIR management exercised ineffective operational control over the line scanning activities. As a result, the ongoing intermittent pressurisation defect was not formally recorded, the issues with the aircraft were not communicated to the AGAIR safety manager, and the hazardous practice of operating the aircraft at a cabin altitude that required the use of supplemental oxygen, without access to a suitable oxygen supply, was allowed to continue.
The signal passed at danger (SPAD) alarm for CS025 did not alert the network control officer when train TE43 passed the signal at stop. This was due to inherent constraints of the universal traffic control system, which was not considered in the way Queensland Rail managed the risk of SPADs.
Response by Queensland Rail
On 11 April 2025, Queensland Rail (QR) acknowledged that there were known circumstances in which Universal Traffic Control (UTC) may not generate a SPAD alarm at all signal locations on the QR Network.
The automatic warning system (AWS) provided the same audible alarm and visual indication to a driver on the approach to all restricted indications. The potential for habituation, and the absence of a higher priority alert when approaching a signal displaying a red aspect, reduced the effectiveness of the AWS to prevent signals passed at danger (SPADs). This placed substantial reliance on procedural or administrative controls to prevent SPADs, which are fundamentally limited in their usefulness.
Batik Air's change management processes were not effective at fully identifying and mitigating the risks associated with the commencement of the Denpasar to Canberra route.
Batik Air did not ensure that flight crew completed all common traffic advisory frequency (CTAF) training prior to them operating flights into Australia where the use of these procedures could be required.
The Civil Aviation Safety Authority guidance for pilots using non-controlled aerodromes did not clearly define the active runway. The guidance did not provide practical advice to pilots using a secondary runway, and in some situations, it was contrary to existing regulations.
The Caboolture Aero Club did not effectively manage or inform pilots of the risk presented by trees and buildings around the airfield that prevented pilots from being able to see aircraft on intersecting runways and approach paths.
The Caboolture Gliding Club had a regular practice of using runway 06 for some flights, including during periods of light traffic on runway 11/29. This increased the risk of collision as Caboolture was a non-controlled aerodrome relying on alerted see-and-avoid principles, and there was a stand of trees obstructing pilots' vision of intersecting runways.
Due to topography and buildings at Mildura Airport, aircraft are not directly visible to each other on the threshold of runways 09, 27 and 36. The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.
The QantasLink radio procedure required Dash 8 flight crews to use the VHF COM 2 radio to broadcast and receive on local frequencies during operations at non-controlled aerodromes. This reduced the ground-based radio transmission and reception strength, and therefore reduced the likelihood of other aircraft receiving calls in some circumstances.
De Havilland Aircraft of Canada Limited did not publish any guidance to operators of Dash 8 aircraft on the transmission and reception performance limitations of VHF COM 2 radios for ground-based communications.
Qantas did not have a procedure to assess cabin crew fitness after a serious injury. This increased the risk that a crew member could continue to operate while being unfit for duty.
Esso Australia did not have a procedure for a helicopter recovery from inadvertent IMC during hoist operations or recovery procedures for EGPWS alerts or advisories.
The Australian Maritime Safety Authority, with direct control of key national emergency response arrangements, did not have the required understanding of its central role in any response, regardless of location. Consequently, its support to, and coordination with, the control agency in relation to emergency towage, salvage and refuge was inadequate, inconsistent with National Plan principles of a single, integrated and comprehensive response and significantly prolonged the emergency.
Portland Bay’s manager, Pacific Basin Shipping, did not provide the master advice about notifying authorities as per the ship’s safety management system emergency procedures, instead focusing on the engineering matters. This probably led to the master delaying the notification and the request for tug assistance.
The Port Authority of New South Wales did not have a proper and correct understanding of its responsibilities for emergency response under its operating licence and relevant state plans. This contributed to the inadequate coordination of emergency towage, salvage and refuge, which were critical for the single, integrated and comprehensive response required and significantly prolonged the emergency.
Response by Port Authority of New South Wales
The Australian Maritime Safety Authority had not adequately managed the National Plan and annual exercises required to prepare for such incidents had not been conducted for 4 years before the incident. This probably resulted in the ineffective implementation of its Maritime Assistance Services procedures, the inefficient process for issuing directions and inadequate coordination of the incident with state authorities.
