The missed approach procedure note on the Cairns runway 15 instrument landing system (ILS) or localiser (LOC) approach chart may inadvertently influence a pilot to commence a turn on the missed approach procedure prior to the published missed approach point.
The Cairns air traffic control procedures that defined a minimum spacing of 5 NM to be established when there were no departures (when the cloud base is less than 1,000 ft and/or visibility is less than 2,000 m) were inadequate to assure separation during a missed approach event and may result in future loss of separation occurrences.
The Cairns air traffic control procedures on the management of missed approaches and the management of successive arriving aircraft were unclear in intent and function, increasing the risk of their incorrect application.
The urgent and priority category defects detected by the AK Car on 4 February 2011 that were located within a 20 m track section were inadequately assessed and controlled in accordance with the ARTC Track and Civil Code of Practice.
AK Car defect exceedence reports produced on 4 February 2011 did not include fields to record the date and time of follow-up field inspections and to show that these inspections and assessment of defects were completed in accordance with the ARTC Track and Civil Code of Practice.
Section 4 of Civil Aviation Advisory Publication (CAAP) 5.23-2(0), Multi engine Aeroplane Operations and Training of July 2007 did not contain sufficient guidance material to support the flight standard in Appendix A subsection 1.2 of the CAAP relating to Engine Failure in the Cruise.
Wear of the interlocking shrouds of the intermediate-pressure turbine blades had the potential to reduce the dampening effects of the feature, and may have led to the development of conditions suitable for fatigue cracking of the IP turbine blades.
The operator’s lack of awareness of the data providers’ assumption that the operator was complying with DO-200A Standards for Processing Aeronautical Data, which was not mandated in Australia, meant that the quality of the data was not assured.
The inconsistent application of the operator’s safety management system to the identification and rectification of database anomalies, and intermittent notification of these anomalies to crews increased the risk of inadvertent flight crew non compliance with published instrument approach procedures.
The safety framework prescribed by successive issues of Marine Orders Part 54 (MO 54) has not assigned the responsibility for the overall management of the safety risks associated with coastal pilotage operations to pilotage providers or any other organisation.
Risk identification and mitigation in coastal pilotage operations is inadequate as a result of the under-reporting of risk events and incidents by pilots.
The potential for the Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS) to support coastal pilotage and enhance safety is under-utilised.
The coastal pilot fatigue management plan is inadequate.
The coastal pilot training program and ongoing professional development is inadequate.
As a measure to assess the adequacy of the individual systems of coastal pilotage and pilot competency, the check pilot system is ineffective.
The operator had limited controls in place to manage the fatigue risk associated with early starts.
Brisbane port authorities had not put in place sufficient procedures, checklists and/or supporting documents to ensure VTS staff were adequately prepared, trained and practiced to handle a predictable incident such as this.
The design of the burner nozzle allowed the nozzle swirl plate and needle valve to be misaligned when being assembled which in turn led to the needle valve stem being damaged during assembly. Furthermore, the maintenance manuals and supporting documentation supplied by Garioni Naval, the thermal oil heater manufacturer, did not provide sufficient guidance to ensure safe and appropriate maintenance of the thermal oil heater burner assembly.
The warning systems in place to alert GWA staff as to the severity of a flood event at the Edith River Rail Bridge were ineffective.
GWA policies, procedures and training had little if any guidance for employees quantifying the duration, consequential dangers and responses to severe weather events.
