Malaysia Airlines’ processes for the management of change did not follow recommended industry practices, and its risk and change management processes were not detailed and clear enough to assure:
Malaysia Airlines did not develop and disseminate guidance and procedures about the use of pitot probe covers to flight crews and engineers, and there was limited awareness among those groups of the need for pitot probe covers at Brisbane Airport.
Malaysia Airlines did not clearly specify the division of engineering responsibilities between Malaysia Airlines and Aircraft Maintenance Services Australia engineers at Brisbane, leading to ambiguity with regard to who should conduct the final walk-around portion of the transit check. This risk was increased by the operator commencing and continuing flights to Brisbane with interim ground handling and engineering arrangements that varied from
Malaysia Airlines flight crew and engineers did not fully complete the required aircraft inspections.
Menzies Aviation staff did not consistently carry out the required arrival and pre-departure aircraft checks of Malaysia Airlines aircraft, and Menzies Aviation audit processes were not effective at evaluating compliance with these requirements.
Aircraft Maintenance Services Australia did not have a reliable method to account for tooling and equipment (such as pitot probe covers) prior to aircraft dispatch when providing non-certifying engineering support.
Some Aircraft Maintenance Services Australia (AMSA) engineers extended the use of pitot probe covers (to mitigate the threat of wasp infestation) to operators that did not explicitly require it, including Malaysia Airlines. This increased the likelihood of error associated with the use of pitot probe covers was because AMSA engineers were not controlling or conducting all of the engineering activities and were not permitted to make technical log entries.
Although suitable for use in most situations, the streamers attached to the pitot probe covers supplied and used for A330 operations by Aircraft Maintenance Services Australia provided limited conspicuity due to their overall length, position above eye height, and limited movement in wind. This reduced the likelihood of incidental detection of the covers, which is important during turnarounds.
In the Airbus A330, there was no auditory alert associated with nil or unreliable airspeed from two or more sources during take-off (a high workload, critical phase of flight). Comparatively, other critical failures provide both visual and auditory indications.
The Airbus guidance provided in the flight crew techniques manual and other manuals for helping A330 flight crews decide whether to continue or reject a take-off did not refer to unreliable airspeed indications.
During the manufacture of the apex pin, the initial machined profile led to unintended stress concentrations at the quench stage of the material heat treatment process that resulted in the part cracking. The crack was not removed by the final machining process.
The Civil Aviation Safety Authority’s acquittal process for repeat safety findings was not effective in ensuring that all previous findings of a similar nature were also appropriately assessed prior to the current and all associated safety findings being acquitted.
Airlines of Tasmania's safety management processes for identifying hazards extensively relied on safety reports. This limited the opportunity to proactively identify the risks in all operational activities, and assess the effectiveness of any controls in place.
Airlines of Tasmania did not provide any documented guidance for the south-west operations, despite encouraging pilots to commence the flight, even when forecasts indicated they may be likely to encounter adverse weather en route. This resulted in the pilots having varied understanding of the expectations regarding in‑flight weather‑related decision making at the Arthur Range saddle, and increased the risk that some pilots continued into an area of high terrain in marginal conditions, where options to escape were limited.
GHD's documented risk assessment for helicopter operations did not consider the hazard of an emergency landing at the drill site. This increased the risk that ground personnel were not clear of the load pick-up area in the event an emergency landing was required.
Encore Aviation's maintenance practices and processes related to inspections, record keeping and trend monitoring, were likely inadequate to detect the potential impending failure of safety critical components.
The operator's ground handling manual did not contain detailed procedural guidance for facilitating accurate redistribution of freight and ensure that an aircraft would be correctly loaded.
Following an assessment of historical data, the aircraft manufacturer, Textron Aviation, replaced a flight hour based repetitive eddy current inspection for cracking of the carry-through structure with a three-yearly visual corrosion inspection for all operation types. This significantly limited the opportunities to identify fatigue cracking within the carry-through structure of low-level survey aircraft prior to a crack reaching a critical size.
It is likely that specific post-flight inspection requirements for the Breeze Eastern rescue hoist listed in Airworthiness Directive AD/SUPP/10 were not adequately completed by the operator. The inspections were targeted at ensuring correct stowage of the hook assembly at the end of each flight.
Civil Aviation Safety Authority (CASA) advisory publications did not include information regarding the potential for reduction in braking performance resulting from active rainfall.
