The Microflite air transport operations risk assessment for poor weather conditions did not consider the risk controls required for inadvertent instrument meteorological conditions. Rather, it relied on their pilots using the actual or forecast conditions to cancel their operations to manage the threat of poor weather.
Microflite did not provide, nor require, their pilots to complete a pre-flight risk assessment for their taskings. A pre-flight risk assessment would have provided pre‑defined criteria to ensure consistent and objective decision-making and reduced the risk of them selecting an inappropriate route.
Microflite had not published an inadvertent instrument meteorological conditions (IIMC) recovery procedure for their day visual flight rules pilots and their IIMC recovery training was not mandatory. The provision of this procedure and training would have reduced the risk of a loss of attitude control following an IIMC encounter.
The Microflite Operator Proficiency Checks did not include a mandatory instrument flight component for their day visual flight rules pilots. This would have reduced the risk of a loss of control event following an inadvertent instrument meteorological conditions encounter.
The operator's hazard and risk register, which formed part of the organisation's safety management system, did not identify inadvertent entry into instrument meteorological conditions as a hazard, which reduced the ability of the organisation to effectively manage the related risk.
The training provider, contracted by the operator to conduct Boeing 737 conversion training, was training pilots to flare at 30 ft rather than the manufacturer’s requirement of 20 ft. This increased the risk of unstable and/or hard landings.
Helibrook’s approved safety management system was not being used to systematically identify and manage operational hazards. As a result, risks associated with conducting human external cargo operations such as carriage of the egg collector above a survivable fall height were not adequately addressed.
Response by Helibrook
The Civil Aviation Safety Authority (CASA) did not have an effective process for assuring an authorisation would be unlikely to have an adverse effect on safety. As a result, CASA delegates did not use the available structured risk management process to identify and assess the risks, ensure appropriate and adequate mitigations were included as conditions of the approval, or assess the effects of changes on the overall risk.
The design of the horizontal stabiliser bungs did not consider aspects that would ensure the identification of an installed bung, or the safe operation of the aircraft if the bungs were not removed prior to flight.
There were no formal procedures for the storage and accountability of horizontal stabiliser bungs after they were removed from the aircraft.
Airservices Australia’s compromised separation recovery training for Sydney tower controllers did not include scenarios involving aircraft below the minimum vector altitude at night.
Airservices Australia did not have procedural controls to separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport while below the minimum vector altitude at night.
Although Airservices Australia 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.
The Airservices Australia MARUB SIX standard instrument departure and the missed approach procedure for runway 34R directed aircraft onto outbound tracks that did not sufficiently assure separation between aircraft following the procedures concurrently.
The balloon manufacturer did not have an adequate process to verify the accuracy of the temperature recorded during production inflation tests.
Regulatory requirements did not ensure that aircraft lighting was adequate to conduct night vision imaging system winching operations safely.
Although the operator’s procedures for winching and night vision imaging system operations included the need to have adequate hover references and a method of recovery in the event of a night vision goggle failure, there was limited guidance to ensure these requirements were confirmed by the flight crew on‑site before commencing precision hover operations.
Toll recency for night vision imaging system (NVIS) winching was insufficient to ensure that complex NVIS winching operations, such as in this occurrence, could be conducted safely.
The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height.
The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions.
