Date Issue Released
Issue number
Issue Owner
Mildura Airport
Safety issue title
Threshold visibility
Safety Issue Description

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.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Airports
Issue number
Issue Owner
De Havilland Aircraft of Canada Limited
Safety issue title
Dash 8 operator guidance
Safety Issue Description

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.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
QantasLink
Safety issue title
Operator radio procedure
Safety Issue Description

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.

Issue Status
Closed – Partially addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways Limited
Safety issue title
Undiagnosed injuries
Safety Issue Description

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.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Esso Australia Pty Ltd
Safety issue title
Crew training
Safety Issue Description

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.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Pacific Basin Shipping
Safety issue title
Ship’s emergency procedures
Safety Issue Description

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.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
United Salvage
Safety issue title
Salvage operation
Safety Issue Description

United Salvage was severely limited in its ability to provide the required salvage services as it did not own, operate or directly control any towage vessels for which it relied on towage providers. This limitation was not made clearly known to Portland Bay’s master, owners or managers or involved authorities to allow them to properly assess whether the most suitable towage vessels, including the emergency towage vessel, had also been promptly deployed for salvage and emergency response.

Response by United Salvage

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Australian Maritime Safety Authority
Safety issue title
Emergency response coordination (AMSA)
Safety Issue Description

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.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Port Authority of New South Wales
Safety issue title
Emergency response coordination (Port Authority of NSW)
Safety Issue Description

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

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Australian Maritime Safety Authority
Safety issue title
Maritime Assistance Services procedures
Safety Issue Description

The Australian Maritime Safety Authority’s Maritime Assistance Services procedures to support the National Plan for Maritime Environmental Emergencies (National Plan) were not effectively implemented. Consequently, there was a 12-hour delay in tasking the state’s nominated emergency towage vessel, Svitzer Glenrock, which significantly prolonged the emergency.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Port Authority of New South Wales
Safety issue title
Port Authority emergency procedures
Safety Issue Description

Port Authority of New South Wales procedures to comply with its Port Safety Operating Licence and the NSW Coastal Waters Marine Pollution Plan were not effectively implemented. This resulted in delays to the required notifications and incident response, which contributed to prolonging the emergency.

Response by Port Authority of New South Wales

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Australian Maritime Safety Authority
Safety issue title
Process for issuing directions
Safety Issue Description

The Australian Maritime Safety Authority’s process to issue directions was inefficient and resulted in excessive time to issue directions allowing Portland Bay to enter Port Botany as a place of refuge. While this delay did not further prolong the emergency, such delays increase risk in time‑critical situations.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Australian Maritime Safety Authority
Safety issue title
National Plan management
Safety Issue Description

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.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Transport for NSW (NSW Maritime)
Safety issue title
Emergency response coordination (NSW Maritime)
Safety Issue Description

Transport for NSW (NSW Maritime), as the statutory agency responsible for ensuring that New South Wales was prepared to respond to an incident in accordance with the state’s plan that it maintained, had not effectively met this obligation. This resulted in the long delay in New South Wales assuming control of the incident and contributed to the inadequate coordination of the emergency response required for a single, integrated and comprehensive response and significantly prolonged the emergency.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Marine
Transport Function
Shore operations
Issue number
Issue Owner
Wave Air
Safety issue title
Stabilised approach decision height
Safety Issue Description

The decision height for assessing whether an aircraft met Wave Air’s stabilised approach criteria was too low.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Wave Air
Safety issue title
Training and assessment of approach speed
Safety Issue Description

The training, supervision and checking flights conducted by Wave Air did not identify that an excessive approach speed was routinely being used by the pilot during the final approach to land.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Wave Air
Safety issue title
Weight and balance calculation
Safety Issue Description

Wave Air's weight and balance system used an incorrect empty weight moment arm to calculate the aircraft's centre of gravity, and passengers were not weighed in accordance with their procedures.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Broome Aviation Pty Ltd
Safety issue title
In-flight fuel management
Safety Issue Description

Broome Aviation’s operations manual did not include a procedure for recording inflight fuel calculations. As a result, pilots adopted varying methods for fuel monitoring, leading to reduced assurance of accurate fuel management.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Broome Aviation Pty Ltd
Safety issue title
Aircraft defect recording
Safety Issue Description

Aircraft defects were not written on the maintenance release, leading to several defects not being rectified or managed.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Broome Aviation Pty Ltd
Safety issue title
Organisational pilot supervision
Safety Issue Description

During the 8-month period from November 2022 until the accident, Broome Aviation provided its pilots transitioning to operating the Cessna 310 with limited supervision, guidance and support, including management of the fuel system.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport