The failure of the digital flight data recorder (DFDR) rack during the tail strike prevented the DFDR from recording subsequent flight parameters.
Operation of the M-18A in accordance with Civil Aviation Safety Authority exemptions EX56/07 and EX09/07 at weights in excess of the basic Aircraft Flight Manual maximum take-off weight (MTOW), up to the MTOW listed on the Type Certificate Data Sheet, may not provide the same level of safety intended by the manufacturer when including that weight on the Type Certificate.
The lack of a requirement for a charter-specific risk assessment in this case meant that the risks associated with the charter were not adequately addressed.
The procedural and guidance framework for commercial balloon operations generally, did not provide a high level of assurance in regard to the safe conduct of low flying.
The Society of Automotive Engineers specification AS7477 was ambiguous in relation to the requirement to cold roll the head-to-shank fillet radius of MS9490-34 bolts.
A number of non-cold rolled bolts were installed on PT6A-67 series engines during manufacture and overhaul
The instructions that were emailed to Mimasaka’s master by NYK-Hinode Line did not provide the crew with proper guidance about how to stow and secure the packs of timber veneer on deck.
The Operation Manual for Loading and Lashing of Tasmanian/Malaysian Dry Veneer, developed by NYK-Hinode Line for use by ships carrying timber veneer, did not contain any information relating to the stowage and securing of the timber veneer cargo on deck.
Mimasaka’s cargo securing manual did not contain any information relating to the stowage and securing of timber veneer.
Ta Ann Tasmania did not follow the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo when they packaged the timber veneer for shipment by sea.
The Australian Maritime Safety Authority had not inspected the packs of veneer to establish whether Ta Ann Tasmania was packaging the veneer in line with the recommendations contained in section 2.3 of Appendix A of the International Maritime Organization’s Code of Safe Practice for Ships Carrying Timber Deck Cargo.
The scheduled maintenance requirements for ex-military UH-1 series helicopters may not adequately address the increased risk of fatigue failures associated with repetitive heavy lifting operations that were not considered in the original design fatigue calculations.
There was no documented evidence that Pacific National actively manages the risk of looseness and fretting damage to bearing components
There were no soft and hard triggers in the operator’s Flight Operational Quality Assurance system to monitor the selection of the aircraft’s landing gear during an approach.
There was no correlation between the results of the operator’s Flight Operational Quality Assurance and Air Safety Incident Report investigations.
The conflicting requirements and definitions in the operator’s publications in relation to the pilot not flying role had the potential to diminish the importance of monitoring as an essential element in an aircraft’s safe operation.
Public Transport Services have not implemented simulator training or a similar interactive system which would allow new drivers to practice, retain and apply what they have learned without the risks associated with driving trains in traffic.
Public Transport Services procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.
There are inconsistencies between Right of Way Work Instructions and the Common General Operating Rules.
SPAD Investigation Form (RS-ADL-283) used by Public Transport Services does not collect data on many of the human factor issues that would facilitate a better understanding of why SPADs are occurring.
