The Regional Express dispatch procedures and training did not explain the appearance, function and importance of the propeller straps or orientation of propeller blades. This provided airport services officers limited guidance on how the propellor strap was used and how to identify it had been removed.
Regional Express did not define the roles and expectations for trainers and trainees during practical ground handling training. During practical training for personnel who had not yet been assessed as competent, there was insufficient clarity for who had responsibility for assuring that safety sensitive checks and other tasks had been conducted.
Queensland Rail did not have an effective means to ensure that operations staff at the Rail Management Centre were aware that environmental management station sensors were unserviceable.
The Queensland Rail alarm response procedure and automated messaging system used at the Rail Management Centre were ineffective in providing network operations staff timely notification of alarms from the environmental monitoring stations in the Glass House Mountains to Gympie North control area.
The Queensland Rail training program did not ensure personnel at the Rail Management Centre proactively monitored an adverse weather event or responded to reports and other information of a condition that could present a hazard to train movements. Subsequently, the network operations personnel relied on the clearance of a signal to determine the integrity of the track through a known flood‑prone area.
The emergency exit pathway through a side window, and the emergency equipment available in the enclosed cab of an Aurizon 2800 class locomotive were inadequate to ensure a prompt escape by crew and potentially limited access by emergency services in the event of a locomotive overturning. This increased the risk of injury to the crew from known evacuation hazards.
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.
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
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 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 aircraft did not have the modifications recommended by CASA for Cessna 206 emergency exits, increasing the likelihood of impeded egress during emergency situations.
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.
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
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:
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.
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.
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.
