Two buildings were constructed north of the runway 12 threshold at a height and position that could generate turbulence affecting the approach, threshold and touchdown areas of the runway under some wind conditions.
The limited consideration of the potential wind impact of the two buildings to the north of runway 12 during northerly wind conditions has resulted in continued operations to that runway in those conditions without any alert to affected pilots about the associated risk.
There were no criteria for assessing the potential wind impact of aerodrome building developments on aircraft operations.
The lack of a reliable mandatory occurrence reporting arrangement minimised the likelihood of an informed response to Papua New Guinea specific safety risks.
The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG) that could enhance the administration of the PNG aviation medical regime.
The oiler’s actions indicate that he was likely not aware of the ship’s safety management system hot work permit requirements.
The oiler’s actions indicate that he was not aware of the dangers associated with the use of an angle grinder to remove the top of the drum.
The voltage of signal JE02 was below the ARTC standard for the type of globe installed.
There was no RailCorp instruction that specifically referred to the need for train crew to prioritise tasks at safety critical locations or at times when workload is high.
The Microlok signalling program design does not meet the requirements of ARTC signalling standard SCP23 ‘Design of Microlok Interlockings’ in regard to the logging of internal bits that initiate flashing, pulsing or toggled outputs.
The operator did not have procedures to assist the crew to ensure that the aircraft was lined up on the runway centreline in preparation for takeoff.
The ammonium nitrate prills were not packaged in the containers in accordance with the requirements of the IMDG Code. The containers were packed in a way which allowed the prills to move within the container in a way that may have contributed to the failure of the containers and/or the lashing system.
The poor condition of much of the ship’s container lashing equipment indicates that the inspection and maintenance regime applied to this critical equipment had been inadequate.
