Sharp Airlines’ Flight crew operating manual required that:
The Recreational Aviation Australia pilot theory examination system did not incorporate sufficient risk controls to ensure that their examination processes were followed as intended and their members had achieved the minimum required knowledge in accordance with the syllabus of flight training.
The Civil Aviation Safety Authority (CASA) Sport and Recreation Aviation Branch did not have a process in place to verify if individuals subject to a suspension from a self‑administering organisation held a CASA licence and to ensure the information was provided to the CASA Coordinated Enforcement Process for review.
The Adventure Flight Training school management practices did not provide the required level of supervision, training and assurance that their graduates had achieved the required level of aeronautical knowledge and understanding for the qualifications they received.
The Heli Surveys Safe Work Method Statements for low-level survey and alpine operations did not identify the operational factors that could affect the control of the helicopter. There was also no requirement for its pilots to conduct a pre-flight risk review for low-level survey operations. Combined, this limited the operator’s ability to manage the possibility of loss of tail rotor effectiveness and ensure that the risks associated with low‑level survey operations were as low as reasonably practicable.
The New South Wales National Parks and Wildlife Service operating procedures referred to, but did not define, ‘essential personnel’, or specify their roles and responsibilities as task specialists when performing aerial work activities.
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 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 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 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.
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.
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 Services procedures required an air attack supervisor (AAS) when 3 or more aircraft were deployed to a fireground. However, there was:
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 formally manage risk in the context of its primary business which was multiple helicopter mustering operations.
Pearl Coast Helicopters did not establish appropriate separation standards for its helicopters or provide documented procedures to ensure pilots established and maintained appropriate separation.
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.
