AirMed required pilots to apply an incorrect landing distance factor, which reduced the safety margin when determining the required landing distance at a destination aerodrome. Furthermore, its procedures were unclear on how the factor should be applied, when the assessment should be conducted and how runway surface condition should be considered.
The type rating training provided by Air Link taught pilots to apply an incorrect landing distance factor, which reduced the safety margin when determining the required landing distance at a destination aerodrome.
On board the Wisdom Venture, a permanent modification to the steam drain line was implemented without documentation. During the modification process, change was not incorporated into a risk assessment and no formal review was conducted. This undocumented change likely introduced a system vulnerability that undermined the effectiveness of the steam system isolation.
Response by master of Wisdom Venture and ship manager
A modification to the cargo heating main steam system drain line was not identified during multiple company superintendent’s visits. This resulted in the Wah Kwong Ship Management (Hong Kong) management of change framework, which required that any system modifications be subject to formal risk assessment and documentation, not being effectively applied.
Response by Wah Kwong Ship Management (Hong Kong)
ASL Airlines Australia employed and promoted pilots earlier than the prescribed minimum experience hours without additional controls in place to manage the risk of lower experienced pilots on the flight deck.
The Kuwait Livestock Transport & Trading Company's planned maintenance system did not provide enough detail to track maintenance schedules, and did not have a specific maintenance item to record the maintenance activities on the main engine pneumatic system.
Response by Kuwait Livestock Transport & Trading Company
The Fremantle Pilots’ operational practice of using VHF channel 8 for communication with Fremantle VTS during Inner Harbour transits was not consistent with the port procedures and prevented effective communication.
Response by Fremantle Pilots
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.
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.
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.
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 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.
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
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 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 aircraft did not have the modifications recommended by CASA for Cessna 206 emergency exits, increasing the likelihood of impeded egress during emergency situations.
