Date Issue Released
Issue number
Issue Owner
Civil Aviation Safety Authority
Safety issue title
Guidance on intersecting runways at non controlled aerodromes
Safety Issue Description

The Civil Aviation Safety Authority guidance for pilots using non-controlled aerodromes did not clearly define the active runway. The guidance did not provide practical advice to pilots using a secondary runway, and in some situations, it was contrary to existing regulations.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
De Havilland Aircraft of Canada Limited
Safety issue title
Dash 8 operator guidance
Safety Issue Description

De Havilland Aircraft of Canada Limited did not publish any guidance to operators of Dash 8 aircraft on the transmission and reception performance limitations of VHF COM 2 radios for ground-based communications.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Mildura Airport
Safety issue title
Threshold visibility
Safety Issue Description

Due to topography and buildings at Mildura Airport, aircraft are not directly visible to each other on the threshold of runways 09, 27 and 36. The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Airports
Issue number
Issue Owner
QantasLink
Safety issue title
Operator radio procedure
Safety Issue Description

The QantasLink radio procedure required Dash 8 flight crews to use the VHF COM 2 radio to broadcast and receive on local frequencies during operations at non-controlled aerodromes. This reduced the ground-based radio transmission and reception strength, and therefore reduced the likelihood of other aircraft receiving calls in some circumstances.

Issue Status
Closed – Partially addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways Limited
Safety issue title
Undiagnosed injuries
Safety Issue Description

Qantas lacked a procedure to assess cabin crew fitness after a serious injury. This increased the risk that a crew member could continue to operate while being unfit for duty.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Esso Australia Pty Ltd
Safety issue title
Crew training
Safety Issue Description

Esso Australia did not have a procedure for a helicopter recovery from inadvertent IMC during hoist operations or recovery procedures for EGPWS alerts or advisories.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Wave Air
Safety issue title
Weight and balance calculation
Safety Issue Description

Wave Air's weight and balance system used an incorrect empty weight moment arm to calculate the aircraft's centre of gravity, and passengers were not weighed in accordance with their procedures.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Wave Air
Safety issue title
Stabilised approach decision height
Safety Issue Description

The decision height for assessing whether an aircraft met Wave Air’s stabilised approach criteria was too low.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Wave Air
Safety issue title
Training and assessment of approach speed
Safety Issue Description

The training, supervision and checking flights conducted by Wave Air did not identify that an excessive approach speed was routinely being used by the pilot during the final approach to land.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Broome Aviation Pty Ltd
Safety issue title
In-flight fuel management
Safety Issue Description

Broome Aviation’s operations manual did not include a procedure for recording inflight fuel calculations. As a result, pilots adopted varying methods for fuel monitoring, leading to reduced assurance of accurate fuel management.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Broome Aviation Pty Ltd
Safety issue title
Organisational pressure
Safety Issue Description

Broome Aviation pilots experienced pressure not to report aircraft defects on maintenance releases, and many pilots also experienced or observed pressure from individuals within the company management to conduct flights in aircraft with defects that they considered made the aircraft unsafe for flight.

Issue Status
Closed – Partially addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Broome Aviation Pty Ltd
Safety issue title
Organisational pilot supervision
Safety Issue Description

During the 8-month period from November 2022 until the accident, Broome Aviation provided its pilots transitioning to operating the Cessna 310 with limited supervision, guidance and support, including management of the fuel system.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Broome Aviation Pty Ltd
Safety issue title
Aircraft defect recording
Safety Issue Description

Aircraft defects were not written on the maintenance release, leading to several defects not being rectified or managed.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Sea World Helicopters Pty Ltd
Safety issue title
Passenger safety briefing content
Safety Issue Description

Sea World Helicopters' passenger safety briefing system, comprising of a passenger safety briefing video supplemented by safety cards and ground crew advice had limited, inconsistent and incorrect information about correct fitment of seatbelts, location and emergency operation of the EC130 doors, and the emergency brace position.

Issue Status
Closed – Partially addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Sea World Helicopters Pty Ltd
Safety issue title
Flight path design
Safety Issue Description

Reopening the Park Pad in March 2022 created an increased risk of collision with traffic operating from the existing heliport. The conflict point was placed at a location where:

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Sea World Helicopters Pty Ltd
Safety issue title
Limitations of ground crew airspace check as a risk control
Safety Issue Description

Sea World Helicopters' procedure did not require ground crew to monitor the airspace up to the time of the helicopter departing the helipad. As the presence of hazards behind the helicopter could change significantly within a short space of time, helicopters routinely departed without current hazard information from ground crew.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Sea World Helicopters Pty Ltd
Safety issue title
Limitations of inbound call as a risk control
Safety Issue Description

Sea World Helicopters' standard inbound call from Porpoise Point was not a reliable alert for a pilot on the ground while boarding and interacting with passengers. Where collision risk on departure existed, a pilot on the ground would highly likely be focused on cabin preparation at the time of that inbound call.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Sea World Helicopters Pty Ltd
Safety issue title
Change management for reopening park pad
Safety Issue Description

Sea World Helicopters' change management process, conducted prior to reopening the park pad, did not encompass the impact of the change on the operator's existing scenic flight operations. Crucially, the flight paths and the conflict point they created were not formally examined, therefore limitations of the operator’s controls for that location were not identified.

Response by Sea World Helicopters

The operator disagreed with this safety issue. It stated:

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Sea World Helicopters Pty Ltd
Safety issue title
Reactive model of separation
Safety Issue Description

Sea World Helicopters' documented procedures for communication between inbound and outbound helicopters were not specific to their usual operation and location, and permitted a reactive model of separation, increasing the likelihood that an outbound pilot would not form awareness of relevant traffic. While some company pilots made proactive calls during final approach, this was not a standard practice.

Response by Sea World Helicopters

The operator disagreed with this safety issue. It stated:

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Sea World Helicopters Pty Ltd
Safety issue title
Withholding of risk controls
Safety Issue Description

Following the change in ownership of Sea World Helicopters, changes to the operation gradually degraded existing controls of enhanced communication and in-cockpit traffic display that informed team situation awareness, and the controls were eventually withheld without formal analysis of the change. This reduced opportunity for company pilots to form and maintain awareness of each other's position and intentions.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation