There were no criteria for assessing the potential wind impact of aerodrome building developments on aircraft operations.
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.
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 lack of a reliable mandatory occurrence reporting arrangement minimised the likelihood of an informed response to Papua New Guinea specific safety risks.
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 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.
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 oiler’s actions indicate that he was likely not aware of the ship’s safety management system hot work permit requirements.
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 voltage of signal JE02 was below the ARTC standard for the type of globe installed.
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.
Before the incident, Orica Australia had advised the Australian Maritime Safety Authority (AMSA) that their packaging method for the prills was fully compliant with the IMDG Code’s provisions. However, AMSA’s IMDG Code compliance audit regime had not detected that the method was not compliant.
At the time of the incident, there was no requirement for any third party to inspect or survey the fixed and loose lashing equipment on a ship. Had this been done, the maintenance and replacement regime of such equipment on board Pacific Adventurer might have been more effective.
