Windshields manufactured with terminal block fittings containing polysulfide sealant (PR1829) have been shown to be predisposed to premature overheating failure that could lead to the development of a localised fire.
The aircraft maintenance manuals did not include the operating specifications of the replacement cabin altitude warning pressure switch hampering the required verification of switch serviceabilty.
The cabin altitude warning pressure switch maintenance manual wiring diagram did not provide a clear indication of the wiring connections for the superseded switch.
There were only subtle cues to the fitment of programming dongles and no requirement to test Emergency Locator Transmitter (ELT) programming after installation, increasing the risk of inadvertent and undetected ELT re-programming and a less effective search and rescue response.
Material characteristics of some the LPT blades installed in engine 858322 were consistent with a raw material manufacturing cast that had previously been identified as being susceptible to creep rupture
The operator did not have a procedure in place to ensure independent cross-checking of the helicopter's fuel quantity.
The controller had not received training in compromised separation recovery techniques.
Ambiguity existed between the Manual of Air Traffic Services and the Aeronautical Information Publication in relation to the assignment of non-standard cruising levels and the definition of an ‘operational requirement’.
Moorabbin GAAP airspace design did not assure lateral or vertical strategic separation between traffic flows. This increased the risk of a mid-air collision.
There was no evidence of any action taken by Airservices to address safety recommendations related to a review of Key Performance Indicators (KPI’s) of GAAP operations.
The aircraft operator did not provide procedures that allowed ground handling personnel to communicate effectively with the flight crew in the event of an urgent operational matter occurring after pushback.
There was no procedure or guidance for the segregation of freight that was rejected during loading.
The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual , with the result that the pilot’s competence and ultimately, safety of the operation could not be assured.
The helicopter landing area was occasionally subjected to rapidly-moving fog or low cloud that increased the risk of flights under the visual flight rules encountering instrument meteorological conditions.
Installation of new cargo door seals resulted in the cargo door being held outside of the flushness requirement specified in the aircraft maintenance manual
Two buildings were constructed north of the runway 12 threshold at a height and position that could generate turbulence affecting the approach, threshold and touchdown areas of the runway under some wind conditions.
The limited consideration of the potential wind impact of the two buildings to the north of runway 12 during northerly wind conditions has resulted in continued operations to that runway in those conditions without any alert to affected pilots about the associated risk.
There were no criteria for assessing the potential wind impact of aerodrome building developments on aircraft operations.
The operator did not have procedures to assist the crew to ensure that the aircraft was lined up on the runway centreline in preparation for takeoff.
By the time of the 28 October 2009 occurrence, many of the operator’s A330 flight crew had not received unreliable airspeed training. Such training started being introduced in the operator’s recurrent training program before the occurrence.
