Date:
Issue number
Safety issue title
Regulatory requirements and guidance for fuel planning of flights to remote islands and isolated aerodromes
Safety Issue Description

Although passenger-carrying charter flights to Australian remote islands were required to carry alternate fuel, there were no explicit fuel planning requirements for other types of other passenger-carrying flights to remote islands. There were also no explicit Australian regulatory requirements for fuel planning of flights to isolated aerodromes. In addition, Australia generally had less conservative requirements than other countries regarding when a flight could be conducted without an alternate aerodrome.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s roles and responsibilities of key personnel
Safety Issue Description

The operator had not formally defined the roles and responsibilities of key positions involved in monitoring and managing flight operations, such as the standards manager for each fleet and the General Manager Flying Operations (Medivac and Charter).

Issue Owner
Pel-Air Aviation
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s hazard identification processes
Safety Issue Description

Although the operator’s safety management processes were improving, its processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations.

Issue Owner
Pel-Air Aviation
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s installation of new aircraft systems on VH-NGA
Safety Issue Description

Although the operator installed an enhanced ground proximity warning system (EGPWS) and traffic alert and collision avoidance system (TCAS) on VH-NGA in August 2009, it did not provide relevant flight crew with formal training on using these systems, or incorporate relevant changes into the aircraft’s emergency procedures checklists.

Issue Owner
Pel-Air Aviation
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s fatigue management
Safety Issue Description

The operator’s application of its fatigue risk management system overemphasised the importance of scores obtained from a bio-mathematical model of fatigue (BMMF), and it did not have the appropriate expertise to understand the limitations and assumptions associated with the model. Overall, the operator did not have sufficient risk controls in addition to the BMMF to manage the duration and timing of duty, rest and standby periods.

Issue Owner
Pel-Air Aviation
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s crew resource management training
Safety Issue Description

Although the operator provided its flight crew with basic awareness training in crew resource management (CRM), it was limited in nature and did not ensure flight crew were provided with sufficient case studies and practical experience in applying relevant CRM techniques.

Issue Owner
Pel-Air Aviation
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s emergency procedures and cabin safety
Safety Issue Description

The operator’s risk controls did not provide assurance that the occupants on an air ambulance aircraft would be able to effectively respond in the event of a ditching or similar emergency. Specific examples included:

Issue Owner
Pel-Air Aviation
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Pre-flight risk assessments for air ambulance tasks
Safety Issue Description

The operator and air ambulance provider did not have a structured process in place to conduct pre-flight risk assessments for air ambulance tasks, nor was there any regulatory requirement for such a process.

Issue Owner
Pel-Air Aviation / CareFlight
Transport Function
Aviation: Air transport
Date issue released
Issue Status
No longer relevant
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s risk controls for in-flight fuel management
Safety Issue Description

The operator’s risk controls did not provide assurance that the operator’s Westwind pilots would conduct adequate in-flight fuel management and related activities during flights to remote islands or isolated aerodromes. Limitations included:

Issue Owner
Pel-Air Aviation
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s risk controls for flight/fuel planning
Safety Issue Description

The operator’s Westwind pilots generally used a conservative approach to fuel planning, and the operator placed no restrictions on the amount of fuel that pilots uploaded. However, the operator’s risk controls did not provide assurance that there would be sufficient fuel on board flights to remote islands or isolated aerodromes. Limitations included:

Issue Owner
Pel-Air Aviation
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Classification of parachuting operations
Safety Issue Description

Classification of parachuting operations in the private category did not provide comparable risk controls to other similar aviation activities that involve the carriage of the general public for payment.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Restraint use in parachuting aircraft
Safety Issue Description

It was likely that the parachutists on the accident flight, as well as those that had participated in previous flights, were not secured to the single-point restraints that were fitted to VH-FRT. While research indicates that single-point restraints provide limited protection when compared to dual-point restraints, they do reduce the risk of load shift following an in-flight upset, which can lead to aircraft controllability issues.

Issue Owner
Occurrence operator
Transport Function
Aviation: General aviation
Date issue released
Issue Status
No longer relevant
Mode of Transport
Aviation
Issue number
Safety issue title
Dual-point restraints
Safety Issue Description

Research has identified that rear‑facing occupants of parachuting aircraft have a higher chance of survival when secured by dual-point restraints, rather than the standard single-point restraints that were generally fitted to Australian parachuting aircraft.

Issue Owner
The Civil Aviation Safety Authority (CASA) and the Australian Parachute Federation (APF)
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Not addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Unapproved aircraft flight control modifications
Safety Issue Description

Some Cessna 206 parachuting aircraft, including VH-FRT, had their flight control systems modified without an appropriate maintenance procedure or approval. That increased the risk of flight control obstruction.

Issue Owner
Civil Aviation Safety Authority (CASA)
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Secondary seat stop modification not mandatory
Safety Issue Description

Despite being categorised as mandatory for the pilot’s seat by the aircraft manufacturer, a secondary seat stop modification designed to prevent uncommanded rearward pilot seat movement and potential loss of control was not fitted to VH-FRT, nor was it required to be under United States or Australian regulations.

Issue Owner
Civil Aviation Safety Authority (CASA)
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Air traffic facilities at Ballina/Byron Gateway Airport
Safety Issue Description

Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence of these facilities, which have been shown to provide good mitigation at other airports with similar traffic levels, increased the risk of a mid-air conflict in the Ballina area.

Issue Owner
Operator-Ballina/Byron Gateway Airport
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Consideration of transient elevator deflections from a pitch disconnect
Safety Issue Description

The aircraft manufacturer did not account for the transient elevator deflections that occur as a result of the system flexibility and control column input during a pitch disconnect event at all speeds within the flight envelope. As such, there is no assurance that the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect.

Issue Owner
ATR
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Emergency oxygen mask and smoke goggles training
Safety Issue Description

At the time of the occurrence, the approved QantasLink training did not provide first officers with sufficient familiarity on the use of the oxygen mask and smoke goggles. This likely contributed to the crew's communication difficulties, including with air traffic control.

Issue Owner
QantasLink
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Absence of air traffic control procedures and tools for runway changes at Melbourne Airport
Safety Issue Description

Airservices Australia did not provide procedures with associated local instructions to Melbourne air traffic controllers regarding how to coordinate runway changes at Melbourne Airport. Furthermore, an absence of system tools increased the risk of the controllers forgetting to coordinate those changes with the Essendon Aerodrome Controller.

Issue Owner
Airservices Australia
Transport Function
Aviation: Airspace management
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Compromised separation recovery training
Safety Issue Description

Compromised separation recovery training deficiencies existed within the Department of Defence at the time of the occurrence, increasing the risk of inappropriate management of aircraft in close proximity.

Issue Owner
Department of Defence
Transport Function
Aviation: Airspace management
Date issue released
Mode of Transport
Aviation