The propeller strap did not have a high-visibility streamer attached, and Link Airways did not effectively manage the condition of propeller straps for its Saab 340B fleet. This affected the visibility of the straps during ground operations.
On one-third of the Link Airways Saab 340B flights for which video surveillance was examined, including the occurrence flight, the flight crews did not fit the strap extension between the propeller strap and the airstairs. As the cabin door could not be closed with the strap extension in place, its correct fitment would almost certainly prevent a flight from proceeding with a propeller strap fitted.
An earlier version of the helicopter operations checklist was used by the crew of the Tai Keystone. That checklist did not include a requirement, present in the version current at the time of the incident, to remove handrails or stanchions from the helicopter landing site.
Although National Jet Systems contained procedures for recognition and management of pilot incapacitation, the associated training did not include the identification and response to subtle physical or cognitive incapacitation.
National Jet Systems’ cabin air quality events procedure focused on the recording/reporting of odours, post-flight care of crew and maintenance actions. However, it did not consider the possible application of the smoke/fumes procedure, or incapacitation procedure. As a result, there was an increased risk of flight crew being adversely affected by such an event during a critical stage of flight.
Although suitable for use in most situations, the streamers attached to the pitot probe covers supplied and used for A350 operations by Heston MRO at Brisbane Airport provided limited conspicuity due to their overall length, position above eye height, and limited movement in wind. This reduced the likelihood of incidental detection of the covers, which is important during turnarounds.
The majority of Singapore Airlines flight crews (observed around the time of the incident) did not fully complete the required pre-flight walk-around inspections.
Heston MRO did not track the work-related hours of personnel with dual management and operational roles (including the licenced aircraft maintenance engineer) for fatigue calculation purposes. Therefore, there was an increased risk of a fatigue related incident involving those personnel.
Heston MRO had not yet implemented a previously proposed and accepted method to account for tooling and equipment (such as pitot probe covers) prior to aircraft pushback.
Arc Infrastructure’s procedures included no requirement for a network control officer (NCO) to make an emergency call and advise potentially ‘at risk’ trains that another nearby train had overrun its limit of authority.
The Arc Infrastructure processes for the management of rail traffic overrunning its limits of authority were reliant on the immediate actions of the rail traffic crew and did not explicitly require immediate actions from the network control officer (NCO). This situation increased the risk of driver completely missed signal passed at danger (SPAD) events, particularly in cases where the rail traffic crew’s awareness or capacity was potentially compromised.
The Arc Infrastructure practice of pathing a following train up to the same section of track occupied by a stopped train, coupled with no requirement for the network control officer (NCO) to communicate and confirm rail traffic crews were aware when approaching another stopped train, increased risk.
Pacific National had limited controls for managing the risk of signals passed at danger during driver only operations, including incidents associated with driver fatigue. The safety system relied on a single driver correctly observing and responding to signals at all times, including during the window of the circadian low (when fatigue risk is greatest).
Pacific National's fatigue management procedures required train drivers to not work if they felt fatigued. This requirement primarily relied on drivers self-reporting if they felt fatigued, and there was no proactive assurance that drivers had obtained adequate sleep, including for higher fatigue risk situations. Self-reporting mechanisms were very seldom utilised and Pacific National had not conducted surveys or used other audit mechanisms or processes to identify any perceived or actual barriers to drivers self-identifying fatigue.
Pacific National’s rostering and fatigue management system used the FAID biomathematical model of fatigue to assess the fatigue risks associated with train driver rosters, applying a threshold FAID score of 80 for driver only operations and 100 for other operations. The operator had not conducted analysis to determine that train drivers working rosters according to these thresholds were sufficiently rested to conduct driving duties.
Qube’s operational procedure for train management between Moss Vale and Inner Harbour did not account for locomotive configurations that maintained locomotive dynamic braking during emergency applications. This increased the risk of the train driver avoiding the use of the emergency brake during a runaway event.
The assumptions regarding locomotive configurations that cut-out locomotive dynamic braking during emergency applications was found embedded in other rollingstock operator’s procedures with similarly configured locomotives in NSW.
The Civil Aviation Safety Authority's Part 133 (air transport - rotorcraft) exposition requirements did not adequately address the risk to passenger safety from a visual flight rules inadvertent instrument meteorological conditions event.
CASA response
On 21 November 2023, the Civil Aviation Safety Authority advised the ATSB that:
The Microflite air transport operations risk assessment for poor weather conditions did not consider the risk controls required for inadvertent instrument meteorological conditions. Rather, it relied on their pilots using the actual or forecast conditions to cancel their operations to manage the threat of poor weather.
Microflite did not provide, nor require, their pilots to complete a pre-flight risk assessment for their taskings. A pre-flight risk assessment would have provided pre‑defined criteria to ensure consistent and objective decision-making and reduced the risk of them selecting an inappropriate route.
