The operator's ground handling manual did not contain detailed procedural guidance for facilitating accurate redistribution of freight and ensure that an aircraft would be correctly loaded.
The absence of authority-overrun protection (such as TPWS) at signal SST535 increased the potential consequences of a SPAD.
Following an assessment of historical data, the aircraft manufacturer, Textron Aviation, replaced a flight hour based repetitive eddy current inspection for cracking of the carry-through structure with a three-yearly visual corrosion inspection for all operation types. This significantly limited the opportunities to identify fatigue cracking within the carry-through structure of low-level survey aircraft prior to a crack reaching a critical size.
The train crew had not been trained to use forced lead function which would likely have allowed the train crew to regain control of the locomotives
Aurizon did not ensure train crews had a consistent understanding of how to safely change ends on banking locomotives
The park brakes were ineffective in holding the locomotives on the grade in Ardglen Yard
It is likely that specific post-flight inspection requirements for the Breeze Eastern rescue hoist listed in Airworthiness Directive AD/SUPP/10 were not adequately completed by the operator. The inspections were targeted at ensuring correct stowage of the hook assembly at the end of each flight.
Civil Aviation Safety Authority (CASA) advisory publications did not include information regarding the potential for reduction in braking performance resulting from active rainfall.
The operator's documentation required crew to consider contamination of runways at the departure and destination airports. However, the provided definition and guidance did not include the means to identify water contamination from active rainfall.
Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities.
The Cessna 206 procedure for ditching and forced landing states that the flaps are to be extended to 40°. While that permits the aircraft to land at a slower speed, it also significantly restricts emergency egress via the cargo door. However, there is no warning about that aspect in the ditching or forced landing pilot’s operating handbook emergency procedures.
Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities.
The inspection procedures in the West Star Aviation maintenance manual supplement for extended life program Cessna 441 aircraft were inadequate to detect the progressive disbonding of the emergency exit door.
Although the operator complied with the regulatory requirements for training and experience of pilots, it had limited processes in place to ensure pilots with minimal time and experience on a new and technically different helicopter type had the opportunity to effectively consolidate their skills on the type required for conducting the operator's normal operations to pontoons.
It was common practice for the operator’s pilots to leave the controls of their helicopter, while the rotors were turning and the friction locks applied, to escort passengers to and from the helicopter.
There was often a significant number of birds located on the pontoons at Hardy Reef used by the operator. However, the operator did not have a process to systematically manage the risk of birdstrike. For example:
Although the operator had calibrated scales available for use at two of their check-in locations, they were not routinely used to ascertain actual passenger and/or baggage weights. Instead, the operator's personnel relied on passengers’ volunteered weights (without an additional allowance) and only weighed passengers when the volunteered weights were perceived to be inaccurate.
The operator’s system used to identify passengers with reduced mobility and/or required additional safety briefing information relied on passengers self-reporting a problem.
Due to multiple factors, the design of the rear left sliding door (emergency exit) on the EC120B helicopter was not simple and obvious to use unless the occupant was provided with specific instructions about how to operate the exit. In particular:
There was no requirement for operators of passenger transport flights in aircraft with six or less seats to provide passengers with a verbal briefing, or written briefing material, on the method for operating the emergency exits.
