The Australian Transport Safety Bureau recommends that Airbus takes safety action to address the effectiveness of the mitigations to the design limitation associated with the A330 cabin pressure control systems.
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.
NSW Trains’ methods of providing safety information to passengers (including verbal safety briefings, onboard guides and signage) did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency.
The ATSB recommends that Eastern Air Link address the safety issue, through provision of guidance and training to flight crew concerning the safest option in the selection of an approach method when weather conditions are marginal for the conduct of a visual approach.
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.
There was no readily available information, for pilots planning to use the helipad, on the pad’s unique characteristics including constraints on operations and, in particularly, the fact that the windsock may provide erroneous wind indications in some weather conditions.
The helipad operator was advised of the safety issue prior to the release of the preliminary factual report and provided the following response on 14 February 2008:
NSW Trains’ methods of providing safety information to passengers (including verbal safety briefings, onboard guides and signage) did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency.
