In the past 25 years the ATSB and its predecessor have investigated 39 collisions between trading ships and smaller vessels on the Australian coast. These investigations have all concluded that there was a failure of the watchkeepers on board one or both vessels to keep a proper lookout and that there was an absence of early and appropriate action to avoid the collision.
Aerial work and private flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.
Pacific National Bulk Rail does not provide coach/tutor drivers with sufficient training and direction as to how to perform their role.
Pacific National’s SPAD strategy focuses on individual crew actions and the costs of SPADs, rather than developing integrated error tolerant systems of work with regard for the broader systemic issues known to contribute to SPAD events.
Pacific National's fatigue management system is over-reliant on the use of a bio-mathematical model to predict individual fatigue risk, being based principally on rostered work hours without due consideration to higher level fatigue risk management strategies.
Pacific National Bulk Rail division did not provide training on fatigue management to the driver.
Aerial work and private flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.
Helicopter flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without the same requirements for autopilots and similar systems that are in place for conducting flights under the instrument flight rules.
Although some of the operator’s risk controls for the conduct of night visual flight rules flights were in excess of the regulatory requirements, the operator did not effectively manage the risk associated with operations in dark night conditions.
The aircraft landing area did not have clearly defined threshold markings making the mown undershoot area difficult to distinguish from the airstrip.
The powerlines were not marked with high visibility devices, nor were they required to be so marked by the relevant Australian Standard. This reduced the likelihood of a pilot detecting the position of the wires.
For approaches other than the one taken by this motor vehicle driver, this level crossing did not meet the requirements of Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings.
A review of the signage requirements for compliance with Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings indicated that the Stop Sign Ahead (W3-1) was missing on the northern side of the Brown Street level crossing.
The Ayers Corporation S2R-G10 Thrush aircraft type had a published maximum take-off weight that was not practical for agricultural use, increasing the risk that pilots would operate the aircraft above the published maximum weight and potentially at unsafe weights.
Although the air traffic services provider has been working on the issue for several years, there was still no automated air traffic conflict detection system available for conflictions involving aircraft that were not subject to radar or ADS-B surveillance services.
Loss of separation (LOS) incidents attributable to pilot actions in civil airspace are not monitored as a measure of airspace safety nor actively investigated for insight into possible improvements to air traffic service provision. As about half of all LOS incidents are from pilot actions, not all available information is being fully used to assure the safety of civilian airspace.
The air traffic controller provider’s processes for monitoring and managing controller workloads did not ensure that newly-endorsed controllers had sufficient skills and techniques to manage the high workload situations to which they were exposed.
Regulatory oversight processes for military air traffic services do not provide independent assessment and assurance as to the safety of civilian aircraft operations.
The air traffic services provider’s fatigue risk management system (FRMS) did not effectively manage the fatigue risk associated with allocating additional duty periods.
There was a disproportionate rate of loss of separation incidents which leads to a higher risk of collision in military terminal area airspace in general and all airspace around Darwin and Williamtown in particular. Furthermore, loss of separation incidents in military airspace more commonly involved contributing air traffic controller actions relative to equivalent civil airspace occurrences.
