The Department of Defence had not provided Darwin-based controllers with regular practical refresher training in identifying and responding to compromised separation scenarios.
The Department of Defence’s risk assessment and review processes for the implementation of the Comsoft Aeronautical Data Access System and removal of the flight data position did not effectively identify or manage the risks associated with the resulting increased workload in the Darwin Approach environment, in particular with regard to the Planner position.
The Darwin Approach long-range display was a low resolution screen that presented air traffic control system information with reduced clarity and resulted in it having diminished effectiveness as a situation awareness tool.
Darwin Approach controllers were routinely exposed to green (limited data block) radar returns that were generally inconsequential in that Approach control environment, leading to a high level of expectancy that such tracks were not relevant for aircraft separation purposes. Refresher training did not emphasise the importance of scanning the green radar returns.
The Australian Defence Air Traffic System (ADATS) did not automatically process all system messages generated by The Australian Advanced Air Traffic System. In cases where transponder code changes were not automatically processed, the risk controls in place were not able to effectively ensure that the changes were identified and manually processed.
The proximity of the landing gear selector valve electrical wiring loom to the external hydraulic power connectors within the left engine nacelle on Fairchild SA227-AT Metro aircraft resulted in the ‘down selection’ wire being damaged during routine maintenance activities.
Although the operator’s rostering practices were consistent with the existing regulatory requirements, it had limited processes in place to proactively manage its flight crew rosters and ensure that fatigue risk due to restricted sleep was effectively minimised.
Jabiru engines manufactured before July 2011 have reduced strength and reliability of the crankshaft/propeller flange joint, compared with the later design that incorporated positive location dowel pins.
The engine manufacturer’s documents with respect to the propeller mounting flange were technically inconsistent with regard to painting and torqueing procedures.
The manufacturer’s specified procedure for assembling and torqueing of the crankshaft/propeller flange fasteners was ineffective in ensuring resistance against subsequent joint movement in service.
The approach to the management of risk at the Old Bar Beach Festival, particularly specifically in relation to aviation activities, was ineffective and resulted in a high level of unmanaged risk that had the potential to impact on the objectives of the festival.
The manufacture of, and the processes used to certify and register the Morgan Aero Works Cheetah Sierra 200 aircraft, resulted in an increased risk to persons entering the recreational aviation community and using the aircraft for flight training, and also to the general public.
The training provided to the pilot did not afford him the opportunity to develop the competencies required to exercise the privileges of the Recreational Aviation Australia Incorporated private pilot certificate.
The operator’s procedures did not require the flight crew to specifically check the active auto-flight mode during descent, and allowed the crew to select the Vertical Intercept Point altitude when cleared for the approach by air traffic control. This combination of procedures provided limited protection against descent through an instrument approach procedure’s segment minimum safe altitudes.
Airservices Australia did not have a defined process for recording the actual hours worked by its Air Traffic Control Line Managers and therefore could not accurately monitor the potential fatigue of those personnel when they were performing operational roles such as a Shift Manager or Contingency Response Manager.
Airservices Australia’s processes for reviewing and testing contingency plans did not effectively ensure that all documented contingency plan details were current and that its contingency plans could be successfully implemented at short notice.
Airservices Australia’s processes for managing a Temporary Restricted Area did not effectively ensure that all aircraft operating in the Temporary Restricted Area were known to air traffic services.
Airservices Australia’s processes for selecting and preparing personnel for the Contingency Response Manager role did not ensure they could effectively perform that role.
The two JRA-776-1 fuselage lateral tie rods fitted to de Havilland DH82A Tiger Moth, registered VH-TSG, had significant, pre-existing fatigue cracks in the threaded sections. The parts’ service life was significantly less than the published retirement life for DH82A tie rods of 2,000 flight hours or 18 years).
The pilot was assigned to a task for which he most likely lacked experience on both the helicopter type and the nature of the flying.
