The Williamtown air traffic control procedures did not clearly define the separation responsibilities and coordination requirements between the Approach sectors for departing aircraft.
An important alerting function within the Australian Defence Air Traffic System had been disabled at Williamtown to prevent nuisance alerts.
The aircraft operator’s flight crews were probably not adequately equipped to manage the vertical profile of non-precision approaches in other than autopilot managed mode.
The presentation on the aircraft load sheet of the zero fuel weight immediately below the operating weight, increased the risk of selecting the inapropriate figure for flight management system data entry.
The operators recurrent simulator training did not address the recovery from a stall or stick shaker activation such that the ongoing competency of their flight crew was not assured.
The operator's procedure for confirming the validity of the flight management system generated take-off weight did not place sufficient emphasis on the check against the load sheet.
The operators procedures did not include a validation check of the landing weight generated by the flight management system which resulted in lack of assurance that the approach and landing speeds were valid.
The current ARTC definition of restricted speed requires considerable judgement on the part of train drivers.
Train drivers receive no formal training with respect to understanding severe weather events, the associated derailment risk and mitigation strategies.
Double stacked container wagons are at particular risk of wind induced roll-over. This is a direct relationship of exposed side area, and was therefore probably exacerbated by out of gauge/high loads on some wagons with a large surface area exposed to the gust front.
The available Cross Crew Qualification and Mixed Fleet Flying guidance did not address how flight crew might form an expectation, or conduct a ‘reasonableness' check, of the speed/weight relationship for their aircraft during takeoff.
When developing the A330/A340 flight control primary computer software in the early 1990s, the aircraft manufacturer’s system safety assessment and other development processes did not fully consider the potential effects of frequent spikes in the data from an air data inertial reference unit.
The implementation of Patrick Terminal’s safety management system resulted in an environment where Patrick Terminal management and stevedores were disconnected in relation to the management of some of the day-to-day workplace safety risks. As a result, there was little ownership of the safe work instructions by the stevedores, and some of the more experienced stevedores were probably no longer aware of the risks posed to them when they undertook unsafe ‘workarounds’ in the workplace and these were not identified by Patrick management.
Patrick Terminals’ risk assessment process for lashing and unlashing operations had not anticipated a fatal accident resulting from being struck by items falling from a portainer or cargo, or from being struck by a moving container. As a result, while the appropriate risk control for this occurrence had been covered during employee training, this was not reinforced in safe work instructions, an important risk control measure.
Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.
Single event effects (SEE) have the potential to adversely affect avionics systems that have not been specifically designed to be resilient to this hazard. There were no specific certification requirements for SEE, and until recently there was no formal guidance material available for addressing SEE during the design process.
The culture which existed in the Patrick terminal did not encourage the reporting of non-compliances or unsafe acts. Consequently, two critical parts of an effective safety system, which had a direct impact upon its ability to effectively manage safety in the terminal, the ‘reporting’ culture and the ‘just’ culture, were either not present or were misunderstood in Patrick’s safety system.
Although passengers are routinely reminded to keep their seat belts fastened during flight whenever they are seated, a significant number of passengers have not followed this advice. At the time of the first in-flight upset, more than 60 of the 303 passengers were seated without their seat belts fastened.
There has been very little research conducted into the factors influencing passengers’ use of seat belts when the seat-belt sign is not illuminated, and the effectiveness of different techniques to increase the use of seat belts.
