Coulson Aviation's safety risk management processes did not adequately manage the risks associated with large air tanker operations. There were no operational risk assessments conducted or a risk register maintained. Further, as safety incident reports submitted were mainly related to maintenance issues, operational risks were less likely to be considered or monitored. Overall, this limited their ability to identify and implement mitigations to manage the risks associated with their aerial firefighting operations.
The New South Wales Rural Fire Service procedures allowed operators to determine when pilots were initial attack capable. However, they intended for the pilot in command to be certified by the United States Department of Agriculture Forest Service certification process.
The New South Wales Rural Fire Service had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision.
The New South Wales Rural Fire Service did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation.
The maximum number of passengers that the balloon operator allowed to be carried meant that there was insufficient room in the basket for them to adopt the landing position specified in the operator's procedures to reduce the risk of injury.
Qantas did not have a procedure for a rapid disembarkation, or other similar procedure that would effectively enable rapid deplaning at a slower and more controlled pace than an emergency evacuation. Therefore, the only option for rapid deplaning was an emergency evacuation utilising slides, which unnecessarily increased the risk of injuries in some situations.
Qantas's cabin crew recurrent training did not include any situation whereby a disarmed door would have to be rearmed in an emergency. This increased the likelihood that a door would be opened without the escape slide deployed, reducing the number of available exits.
Qantas's cabin crew primary evacuation commands did not include phrases such as 'leave everything behind' and 'jump and slide'; instead, these phrases were optional. Consequently, passengers would generally not receive specific guidance until they reached an exit, which would likely slow down the evacuation.
Qantas’s method of briefing passengers provided limited and inconsistent information about how to use the escape slides safely and what to do with cabin baggage in an emergency.
The sleep log tool used by the operator contained a coding error and it also pre-loaded sleep periods of future nights by default. This combination of factors reduced the likelihood pilots would identify fatigue risks associated with insufficient sleep and extended wakefulness.
The operator's fatigue risk management system relied extensively on a sleep reporting spreadsheet (sleep log) that was based on the prior sleep wake model, and the spreadsheet had a transparent rule set that made the recorded data easy to modify to achieve results that met the operator’s minimum sleep and wake requirements.
The operator’s circuit and approach procedures for marine pilot transfer operations did not minimise pilot workload or provide the recommended stabilised approach criteria with mandatory go-around policy. These procedures could allow a combination of conditions that increased the risk of a sustained abnormal flight path and collision with terrain/water.
The operator's training and assessing procedures for marine pilot transfer operations did not provide assurance that pilot under supervision experience, helicopter instrumentation, and instructor capability were suitable for line training at night in a degraded visual cueing environment.
The instrument panels fitted to VH-ZGA and the operator's other EC135 helicopter at Port Hedland were equipped for single-pilot operation under the instrument flight rules. When used for flight training or checking in a degraded visual cueing environment, this configuration has a detrimental effect on the ability of an instructor or training/check pilot to monitor the helicopter's flight path and take over control if required.
Changes in the operator's key safety post holder positions, safety reporting systems and internal processes reduced effective safety assurance.
The operator’s training for the Fokker F28-Mk0100 did not prepare pilots for alpha mode activation during critical phases of flight.
The operator’s safety management reporting system did not enable the effective prioritisation of submitted safety reports.
The helicopter operator's traffic alert and collision avoidance system knowledge was inadequate with respect to resolution advisory alert terrain considerations and the required intensity of response manoeuvring.
The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height., This delayed the identification and recovery from the unsafe aircraft state resulting in the pilot not identifying the developing rate of descent during the incident, delaying the recovery from the descent.
The En-Route Supplement Australia included a requirement to add 1,000 ft to the prescribed practice instrument approach ‘altitude’ at Mangalore Airport. The procedure did not detail whether this height was to be applied to the minimum descent altitude or to all approach altitudes, resulting in varied application and an increased risk of traffic conflicts. (Safety issue).
