Changes in the operator's key safety post holder positions, safety reporting systems and internal processes reduced effective safety assurance.
The operator’s training for the Fokker F28-Mk0100 did not prepare pilots for alpha mode activation during critical phases of flight.
The operator’s safety management reporting system did not enable the effective prioritisation of submitted safety reports.
The helicopter operator's traffic alert and collision avoidance system knowledge was inadequate with respect to resolution advisory alert terrain considerations and the required intensity of response manoeuvring.
The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height., This delayed the identification and recovery from the unsafe aircraft state resulting in the pilot not identifying the developing rate of descent during the incident, delaying the recovery from the descent.
The En-Route Supplement Australia included a requirement to add 1,000 ft to the prescribed practice instrument approach ‘altitude’ at Mangalore Airport. The procedure did not detail whether this height was to be applied to the minimum descent altitude or to all approach altitudes, resulting in varied application and an increased risk of traffic conflicts. (Safety issue).
The Civil Aviation Safety Authority review of the airspace surrounding Ballina Byron Gateway Airport did not include data for aircraft transiting the airspace without using the airport. Therefore, the risk associated with occurrences such as this one were not specifically considered when assessing the appropriate airspace classification.
The Lido airport operational information did not include the Australian Aeronautical Information Publication (AIP) advice to fit pitot probe covers at Brisbane Airport (related to significant mud wasp activity), as well as other safety AIP information.
Malaysia Airlines’ processes for the management of change did not follow recommended industry practices, and its risk and change management processes were not detailed and clear enough to assure:
Malaysia Airlines did not develop and disseminate guidance and procedures about the use of pitot probe covers to flight crews and engineers, and there was limited awareness among those groups of the need for pitot probe covers at Brisbane Airport.
Malaysia Airlines did not clearly specify the division of engineering responsibilities between Malaysia Airlines and Aircraft Maintenance Services Australia engineers at Brisbane, leading to ambiguity with regard to who should conduct the final walk-around portion of the transit check. This risk was increased by the operator commencing and continuing flights to Brisbane with interim ground handling and engineering arrangements that varied from
Malaysia Airlines flight crew and engineers did not fully complete the required aircraft inspections.
Menzies Aviation staff did not consistently carry out the required arrival and pre-departure aircraft checks of Malaysia Airlines aircraft, and Menzies Aviation audit processes were not effective at evaluating compliance with these requirements.
Aircraft Maintenance Services Australia did not have a reliable method to account for tooling and equipment (such as pitot probe covers) prior to aircraft dispatch when providing non-certifying engineering support.
Some Aircraft Maintenance Services Australia (AMSA) engineers extended the use of pitot probe covers (to mitigate the threat of wasp infestation) to operators that did not explicitly require it, including Malaysia Airlines. This increased the likelihood of error associated with the use of pitot probe covers was because AMSA engineers were not controlling or conducting all of the engineering activities and were not permitted to make technical log entries.
Although suitable for use in most situations, the streamers attached to the pitot probe covers supplied and used for A330 operations by Aircraft Maintenance Services Australia provided limited conspicuity due to their overall length, position above eye height, and limited movement in wind. This reduced the likelihood of incidental detection of the covers, which is important during turnarounds.
In the Airbus A330, there was no auditory alert associated with nil or unreliable airspeed from two or more sources during take-off (a high workload, critical phase of flight). Comparatively, other critical failures provide both visual and auditory indications.
The Airbus guidance provided in the flight crew techniques manual and other manuals for helping A330 flight crews decide whether to continue or reject a take-off did not refer to unreliable airspeed indications.
During the manufacture of the apex pin, the initial machined profile led to unintended stress concentrations at the quench stage of the material heat treatment process that resulted in the part cracking. The crack was not removed by the final machining process.
The Civil Aviation Safety Authority’s acquittal process for repeat safety findings was not effective in ensuring that all previous findings of a similar nature were also appropriately assessed prior to the current and all associated safety findings being acquitted.
