The Manual of Air Traffic Services did not explicitly state that sequencing instructions were required to be read back by a pilot, providing no assurance that this safety-critical aspect had been correctly understood.
Pearl Coast Helicopters did not establish appropriate separation standards for its helicopters or provide documented procedures to ensure pilots established and maintained appropriate separation.
Pearl Coast Helicopters did not formally manage risk in the context of its primary business which was multiple helicopter mustering operations.
The Civil Aviation Safety Regulations Part 139 Manual of Standards did not recommend or provide standardised options for movement area guidance signs or other visual aids to draw flight crew attention to the start of take-off position, especially those distant from a displaced threshold and not coincident with a taxiway/runway intersection.
QantasLink's radio procedure required crew to use communications panel radio 2 (COM 2) to broadcast and receive on local frequencies during operations at a non‑controlled aerodrome. This reduced the likelihood of the Dash 8 receiving the calls from other aircraft at either end of runway 05/23 at Wagga Wagga in certain circumstances.
The Australian Airline Pilot Academy flying school flight crew operation manual only required pilots to select ALT on the transponder, as part of the Pre Line Up Scan Action Flow and associated Checklist prior to entering the runway. The use of a transponder during taxi would normally provide an additional source of positional data to other pilots, aiding visual identification and alerted 'see‑and‑avoid' to other aircraft.
The International Civil Aviation Organization (ICAO) Annex 14 standards and recommended practices did not recommend, or provide standardised options for, movement area guidance signs or other visual aids to provide enhanced flight crew situational awareness of temporary changes to the runway length available for take-off.
Malaysia Airlines did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety.
Bamboo Airways did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety.
The Australian Aeronautical Information Publication requirement for flight crews to confirm automatic terminal information service (ATIS) identifier with air traffic control did not provide positive assurance that crews had received the information in full, which included essential information on aerodrome conditions, and there were no standard air traffic control communication procedures for providing this assurance.
The Part 139 (Aerodromes) Manual of Standards 2019 did not recommend, or provide standardised options for, movement area guidance signs or other visual aids to provide enhanced flight crew situational awareness of temporary changes to the runway length available for take-off.
The International Civil Aviation Organization (ICAO) Annex 11 requirement for flight crews to confirm automatic terminal information service (ATIS) identifier with air traffic control did not provide positive assurance that crews had received the information in full, which included essential information on aerodrome conditions, and there were no standard air traffic control communication procedures for providing this assurance.
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.
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.
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.
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.
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.
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
