Version 3 of the Damoda ground control station software included a wind speed readout, but did not actively alert the pilot if the wind speed limit was exceeded. This increased the risk that a pilot would fail to identify a limit exceedance and continue a show into unsafe conditions.
Response By Damoda Intelligent Control Technology Co., Ltd
The operator did not provide formal training on version 3 of the ground control station software to its pilots. Instead, relying on familiarisation flights and ad hoc advice from the manufacturer. This increased the risk that show-qualified pilots would fail to identify exceedances in flight critical parameters and experience increased workload.
Following the introduction of a weather drone option to the wind management plan in June of 2023, the operator had not updated its operational procedures to include this option. As a result, flight crew were not prompted to use this method for gathering information on wind conditions in the show area prior to launch.
MAGSPEC Aviation's safety risk management processes did not include a pre‑operational risk assessment that recognised the generic risks and hazards common across that type of operation nor was a risk register maintained. Consequently, there was limited assurance that all the risks had been identified and that all reasonable mitigations had been applied.
Response by MAGSPEC Aviation Pty Ltd
The Robinson Helicopter pilot’s operating handbook sections for operation in high winds or turbulence did not warn of the potential for turbulence-induced low‑G, and rapid right roll, particularly at high airspeed or provide guidance for appropriate control inputs in response to a turbulence-induced low‑G situation. This increased the risk of pilots encountering low‑G independent of control inputs, and an in‑flight break‑up.
Response by Robinson Helicopter Company
The aircraft did not have the modifications recommended by CASA for Cessna 206 emergency exits, increasing the likelihood of impeded egress during emergency situations.
The asymmetric horizontal stabiliser design in the Robinson R22, R44 and R66 models significantly contributed to the uncommanded right roll rate during low‑G conditions and the risk of an in‑flight break‑up.
Response by Robinson Helicopter Company
The operator’s pre-flight passenger briefing did not include the demonstration of, and pilots were not trained how to operate, the emergency exit via the cargo door with the flaps extended.
V/Line inspection regime did not identify that the interface between the unsealed road and Barwon Terrace level crossing was a safety risk. Inspections did not extend to the routine review of any changing road conditions that may heighten risk.
The Civil Aviation Safety Regulations Part 139 (Aerodromes) Manual of Standards 2019 section relating to the temporary closure of a taxiway at night did not:
Rules and procedures associated with managing trains between Bayswater and Upper Ferntree Gully were inconsistently applied and gaps in the recording protocols at Ringwood probably impacted the effectiveness of the administrative systems.
At Upper Ferntree Gully (and some other parts of the MTM network), the issuing of a caution order did not require validation by a second person.
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.
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.
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 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.
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.
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.
