The Caboolture Aero Club did not effectively manage or inform pilots of the risk presented by trees and buildings around the airfield that prevented pilots from being able to see aircraft on intersecting runways and approach paths.
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.
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.
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.
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.
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.
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.
The decision height for assessing whether an aircraft met Wave Air’s stabilised approach criteria was too low.
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.
Aircraft defects were not written on the maintenance release, leading to several defects not being rectified or managed.
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.
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.
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.
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:
Sea World Helicopters was reliant on CTAF calls, ground crew advice, and pilot visual detection of aircraft to ensure separation in VH-XH9 and VH-XKQ. Available additional controls for enhancing alerted see-and-avoid and reducing the risk of collision were not implemented.
Response by Sea World Helicopters
Sea World Helicopters provided the following response:
SWH state that additional controls for alerted See and Avoid were available.
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.
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:
Sea World Helicopters' implementation of their SMS did not effectively manage aviation safety risk in the context of the operator's primary business. Additionally, their objectives were non-specific, and the focus of safety management was primarily ground handling and WHS issues. This limited the operator's ability to ensure that aviation safety risk was as low as reasonably practicable.
Response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
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.
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:
