The minimal clearance from obstructions, unfavourable surface conditions and a lack of appropriate wind indication at the helicopter landing site (HLS) increased the risk associated with operations to the HLS, particularly for a pilot unfamiliar with the site.
The nut manufacturer’s production control and quality control processes failed to prevent the release of one or more lots of MS21042L-4 nuts that remained in a partially-embrittled state after cadmium electroplating.
At the time of the occurrence there was limited advisory material available to owners, operators and maintenance personnel to alert them to the possibility of MS21042 nut failure and to assist with appropriately detailed inspections aimed at identifying affected items.
Though airborne search and rescue service providers were regularly tasked to provide assistance to pilots in distress, there was limited specific guidance on the conduct of such assistance.
The Manual of Air Traffic Services differed from the Civil Aviation Safety Regulation Part 172 Manual of Standards concerning the requirements for issuing a night visual approach to an instrument flight rules aircraft, increasing the risk of ambiguity in the application of these requirements by controllers.
The Tiger Airways Australia Pty Ltd documentation and training package relating to the Avalon airspace structure and night visual approach guidance contained incorrect material and omissions that increased the risk of confusion and misunderstanding by flight crews.
Local and national air traffic control procedures did not prescribe the means for controllers to indicate in the air traffic control system that a parachute drop clearance had been issued.
There was no documented procedure for assuring the separation of aircraft departing from Sydney with parachute operations at Richmond, increasing the likelihood that Sydney Terminal Control Unit controllers would have differing expectations as to their control and coordination requirements in respect of these operations.
Aerial work and private flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.
Aerial work and private flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.
Helicopter flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without the same requirements for autopilots and similar systems that are in place for conducting flights under the instrument flight rules.
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.
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 to controllers and pilots regarding the conditions in which it was safe and appropriate to use block levels.
