Research has identified that rear‑facing occupants of parachuting aircraft have a higher chance of survival when secured by dual-point restraints, rather than the standard single-point restraints that were generally fitted to Australian parachuting aircraft.
Some Cessna 206 parachuting aircraft, including VH-FRT, had their flight control systems modified without an appropriate maintenance procedure or approval. That increased the risk of flight control obstruction.
Despite being categorised as mandatory for the pilot’s seat by the aircraft manufacturer, a secondary seat stop modification designed to prevent uncommanded rearward pilot seat movement and potential loss of control was not fitted to VH-FRT, nor was it required to be under United States or Australian regulations.
The inspection regime to identify rail fractures was ineffective for the condition of this track.
Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence of these facilities, which have been shown to provide good mitigation at other airports with similar traffic levels, increased the risk of a mid-air conflict in the Ballina area.
Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.
The procedures for measuring, assessing, and remediating rail creep in spring did not ensure creep defects were addressed in a timely manner and prior to the onset of hot weather. A creep defect identified by the spring measurements was not corrected before the derailment.
There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.
Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.
While TT-Line Company’s standard mooring line pattern for ships at Station Pier had been successfully used for many years, the breakaway indicated the risk could have been further reduced to better prepare for such unusual circumstances.
The Port of Melbourne vessel traffic service (VTS) procedures for adverse weather were not comprehensive and, hence, its response on 13 January was only partially effective. One important consequence was that VTS’s advance warning of storm force winds did not reach all relevant parties, including Spirit of Tasmania II’s master.
The adverse weather procedures for TT-Line Company ships when alongside did not take into account all the necessary factors to provide effective defences against significant, short-term weather events such as thunderstorms and squalls.
The aircraft manufacturer did not account for the transient elevator deflections that occur as a result of the system flexibility and control column input during a pitch disconnect event at all speeds within the flight envelope. As such, there is no assurance that the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect.
At the time of the occurrence, the approved QantasLink training did not provide first officers with sufficient familiarity on the use of the oxygen mask and smoke goggles. This likely contributed to the crew's communication difficulties, including with air traffic control.
Airservices Australia did not provide procedures with associated local instructions to Melbourne air traffic controllers regarding how to coordinate runway changes at Melbourne Airport. Furthermore, an absence of system tools increased the risk of the controllers forgetting to coordinate those changes with the Essendon Aerodrome Controller.
The rule describing the required driver response to a Distant signal at Caution in a two-position signalling system did not fully reflect the signalling system design principles.
The training and assessment of the driver did not ensure that he had an adequate understanding of the two-position signalling through Marshall.
The Queensland Rail network rules, procedures and safety manual provided insufficient guidance to identify the magnitude of the potential hazard from a weather event, or define the response when encountering water that had previously overtopped the track and receded or was pooled against the track formation or ballast.
The Queensland Rail General Operational Safety Manual (MD-10-107) contained insufficient guidance for rail traffic crews to ensure the timely identification and management of a potential hazard (resulting from a weather event) that might affect the safe progress of the train.
Compromised separation recovery training deficiencies existed within the Department of Defence at the time of the occurrence, increasing the risk of inappropriate management of aircraft in close proximity.
