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.
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. Using this approach method, rather than a straight in instrument approach, significantly reduced obstacle clearance assurance for both an approach and any potential missed approaches, and also increased the risk to both the operator’s and other aircraft through the use of a non-standard circuit procedure.
The aircraft system to be used in the event of a main deck cargo smoke event on the operator’s B737 fleet was being routinely used by the operator’s engineering personnel in Darwin as a means to cool the flight deck. This practice had become normalised as a result of the perceived benefit of doing so, but there were insufficient risk controls in place to ensure that the aircraft would be returned to the correct configuration prior to departure.
Recommendations in CASA guidance CAAP 92-1(1) requiring obstacle clearance out to 900 m may lead to circumstances where ALAs meet these requirements however, aircraft are required to manoeuvre below a safe height or be unable to outclimb rising terrain after take-off more than 900 m past the runway end.
The CASA sample operations manual used by the operator that allowed any aerodrome in the Enroute Supplement Australia to be used for flight training did not assure that these aerodromes were suitable for use.
Response by Civil Aviation Safety Authority (CASA)
On 23 January 2023, CASA provided the following response with respect to this safety issue.
Network Aviation did not include the threat of unforecast weather below landing minima in their controlled flight into terrain risk assessments. This increased the risk that controls required to manage this threat would not be developed, monitored, and reviewed at a management level.
