Although some of the operator’s risk controls for the conduct of night visual flight rules flights were in excess of the regulatory requirements, the operator did not effectively manage the risk associated with operations in dark night conditions.
The aircraft landing area did not have clearly defined threshold markings making the mown undershoot area difficult to distinguish from the airstrip.
The powerlines were not marked with high visibility devices, nor were they required to be so marked by the relevant Australian Standard. This reduced the likelihood of a pilot detecting the position of the wires.
The Ayers Corporation S2R-G10 Thrush aircraft type had a published maximum take-off weight that was not practical for agricultural use, increasing the risk that pilots would operate the aircraft above the published maximum weight and potentially at unsafe weights.
Although the air traffic services provider has been working on the issue for several years, there was still no automated air traffic conflict detection system available for conflictions involving aircraft that were not subject to radar or ADS-B surveillance services.
The air traffic controller provider’s processes for monitoring and managing controller workloads did not ensure that newly-endorsed controllers had sufficient skills and techniques to manage the high workload situations to which they were exposed.
The air traffic services provider’s fatigue risk management system (FRMS) did not effectively manage the fatigue risk associated with allocating additional duty periods.
The air traffic services provider had limited formal guidance to controllers and pilots regarding the conditions in which it was safe and appropriate to use block levels.
Although the air traffic services provider has been working on the issue for several years, there was still no automated air traffic conflict detection system available for conflictions involving aircraft that were not subject to radar or ADS-B surveillance services.
The air traffic services provider had limited formal guidance regarding how to determine appropriate consolidation periods for en route controllers on one sector before they were transitioned to commence training on another sector.
The air traffic services provider’s processes for monitoring and managing controller workloads did not ensure that newly-endorsed controllers had sufficient skills and techniques to manage the high workload situations to which they were exposed.
Limited guidance was provided by the operator and Air Ambulance Victoria for to crews on the selection of the most appropriate winch rescue equipment given operational and medical considerations, and the conditions when various types of equipment should be considered.
The threshold limits for the engine trend monitoring program were not set at a level that provided sufficient opportunity for inspection of the engine before failure could occur from the effects of HPT stage-2 nozzle degradation.
The design cooling characteristics of the Engine Alliance GP7200 high pressure turbine (HPT) stage-2 nozzle components led to higher than expected metal surface temperatures during operation, rendering the nozzles susceptible to distress, premature degradation and failure.
The Civil Aviation Regulations 1988 lack clarity regarding the requirement for aircraft manufacturers’ supplemental inspections, where available, to be carried out when an aircraft is being maintained in accordance with the CASA maintenance schedule.
The Civil Aviation Regulations 1988 allow class B aircraft registration holders to maintain their aircraft using the CASA maintenance schedule in situations where a more appropriate manufacturer’s maintenance schedule exists.
The Australian Transport Safety Bureau advises balloon operators to review their risk controls in relation to the safety of cold-air inflation fans, especially in relation to passenger proximity to operating fans, and the security of loose items, such as passenger clothing.
The evolution of the current advisory material relating to the minimisation of hazards resulting from uncontained engine rotor failures was based on service experience, including accident investigation findings. The damage to Airbus A380-842 VH-OQA exceeded the modelling used in the UERF safety analysis and, therefore, represents an opportunity to incorporate any lessons learned from this accident into the advisory material.
The engine manufacturer did not require its manufacturing engineers to consult with the design engineers to ensure that design intent would be maintained when introducing manufacturing datums.
The engine manufacturer's process for retrospective concessions did not specify when in the process the Chief Engineer and Business Quality Director approvals were to be obtained. Having them as the final approval in the process resulted in an increased probability that the fleet-wide risk assessment would not occur.
