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 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 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 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 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 current ARTC definition of restricted speed requires considerable judgement on the part of train drivers.
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.
Train drivers receive no formal training with respect to understanding severe weather events, the associated derailment risk and mitigation strategies.
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.
There was a limitation in the algorithm used by the A330/A340 flight control primary computers (FCPCs) for processing angle of attack (AOA) data. This limitation meant that, in a very specific situation, multiple spikes in AOA from only one of the three ADIRUs could result in a nose-down elevator command.
Patrick Terminals’ safe work instructions for lashing/unlashing did not specifically cover the recognised safe practices of not working under containers or between moving containers and fixed objects. Consequently, there was a discontinuity between the level of awareness regarding these dangers and the training new employees received during their induction period.
Industry practices for tracking faults or performance problems with line-replaceable units are limited, unless the units are removed for examination. Consequently, the manufacturers of aircraft equipment have incomplete information for identifying patterns or trends that can be used to improve the safety, availability or reliability of the units.
Although passengers are routinely advised after takeoff to wear their seat belts when seated, this advice typically does not reinforce how the seat belts should be worn.
One of the aircraft’s three air data inertial reference units (ADIRU 1) exhibited a data-spike failure mode, during which it transmitted a significant amount of incorrect data on air data parameters to other aircraft systems, without flagging that this data was invalid. The invalid data included frequent spikes in angle of attack data. Including the 7 October 2008 occurrence, there have been three occurrences of the same failure mode on LTN-101 ADIRUs, all on A330 aircraft.
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.
Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.
For the data-spike failure mode, the built-in test equipment of the LTN 101 air data inertial reference unit was not effective, for air data parameters, in detecting the problem, communicating appropriate fault information, and flagging affected data as invalid.
The recognised safe practices of not working under or near a container being loaded is not well reflected in national and international guidance published to assist container terminal operators develop their own safety policies and guidelines.
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.
