Although required by the harness instrument commonly issued by the Civil Aviation Safety Authority, the operator did not appraise shooting crews of the risks of using only a harness for restraint during low-level flight.
A harness instrument, commonly issued by the Civil Aviation Safety Authority (CASA), stated that a harness could be used instead of a seatbelt for take-off and landing. Although not intended by CASA, this instrument was easily able to be misinterpreted as indicating that a seatbelt was not required to be used during take-off and landing.
Recurrency training and drills in aircraft emergencies were not required for reissue of an aerial platform shooting permission. Some shooters last conducted training about 20 years prior, during initial issue of their permissions.
The Director of National Parks did not actively manage the risk of the aerial culling task being conducted in the Kakadu National Park, or effectively supervise the operation. As a result, an increase in the number of crew, a change in helicopter type and change of helicopter operator all progressed without requisite risk management. This exposed crew to avoidable harm during low-level aerial shooting operations.
Although the Director of National Parks’ safe operating procedures required shooters and spotters to wear helmets during aerial culling tasks, helmets were not provided or used on a routine basis.
Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in important safety issues not being identified, which may remain a hazard to current and future passenger carrying operations.
There was no regulatory requirement from the Civil Aviation Safety Authority for piston‑engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin.
Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non‑identification of safety issues, which continue to present a hazard to current and future passenger-carrying operations.
Response by the Civil Aviation Safety Authority
Although detectors were not required to be fitted to their aircraft, Sydney Seaplanes had no mechanism for monitoring the serviceability of the carbon monoxide detectors.
While the manufacturer's instructions for the zonal inspections detailed that installation blankets could be removed 'as necessary', they did not reference the insulation blanket installation procedure. This resulted in insulation blankets not being secured to the structure.
Pacific National’s inspection processes did not identify key structural points for inspection on RRYY class wagons, including the susceptibility to cracking in the junction between container loading outriggers, pull rod boxed opening, and the bottom centre sill sections. This reduced the likelihood of cracks being detected.
Pratt & Whitney Canada (PWC) PT6A-114A engines fitted with compressor turbine vane rings that have been repaired in accordance with the United States Federal Aviation Administration‑approved scheme STI 72-50-254 have a significantly increased likelihood of CMSX-6 compressor turbine blade fracture and subsequent failure of the engine compared to those engines fitted with PWC‑manufactured compressor turbine vane rings.
The ARTC systems for managing track lateral stability did not lead to the location being managed as a location potentially vulnerable to instability.
Response by Australian Rail Track Corporation (ARTC)
Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.
Virgin Australia Airlines did not require ATR flight crews to complete the Before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying was critical.
Pacific National's Freight Loading Manual did not require the use of radial unitising straps to prevent telescoping on jumbo coils where the thickness of the steel was greater than 2 mm.
Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose.
Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of strap breakage due to contact with the cradle.
Pacific National's Freight Loading Manual, specific to the loading and unitising of jumbo coils, did not require the use of rubber load mat on cradles. Consequently, there was no requirement to consider the condition of load mat during inspection and maintenance. This allowed the continued use of cradles without load mat, which decreased their effectiveness at restraining loads.
Neither Alstom’s validation processes nor fault monitoring processes were sufficient to detect the overcharging of batteries prior to the event.
