The absence of simulator training meant that the endorsement and other training the flight crew had undergone did not adequately prepare them for the event.
The practices used by the operator’s pilots for measuring and logging of fuel quantity were inconsistent.
There was no regulatory requirement for simulator training in Australia.
Response from CASA: 31/08/2009
CASA will address this issue and will commence a review of the legislation. In the course of that review, CASA will consider whether there is a need to mandate the use of simulators in connection with certain flight crew training requirements in the air transport sector, and other sectors where this may be appropriate.
Likely due to a training deficiency, Alliance Airlines flight crews' conduct of the Before start procedures and Pre-take-off brief review were not being performed effectively to ensure the speed selector knob was correctly set and checked, which increased the risk of a low-speed event after take-off.
CASA did not seek information to establish whether there was ‘evidence of risk to third parties on land, sea or air’ prior to issuing the Special Certificate of Airworthiness.
Although Airservices Australia used applied operational risk assessments to high-level threats, it did not formally assess and manage the risk of specific threat scenarios. As a likely result, Airservices did not formally identify and risk manage the threat of separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport, even though it had been a known issue among controllers generally.
