Microflite had not published an inadvertent instrument meteorological conditions (IIMC) recovery procedure for their day visual flight rules pilots and their IIMC recovery training was not mandatory. The provision of this procedure and training would have reduced the risk of a loss of attitude control following an IIMC encounter.
The Microflite Operator Proficiency Checks did not include a mandatory instrument flight component for their day visual flight rules pilots. This would have reduced the risk of a loss of control event following an inadvertent instrument meteorological conditions encounter.
The operator's hazard and risk register, which formed part of the organisation's safety management system, did not identify inadvertent entry into instrument meteorological conditions as a hazard, which reduced the ability of the organisation to effectively manage the related risk.
Network pre-start briefings are a critical control in place to manage the risk of collisions between rail traffic and workers and machinery, and Queensland Rail had undertaken significant work to improve these processes. However, the design of the first-line assurance activities and the limited conduct of second-line and third-line assurance activities provided only limited assurance that the worksite protection aspects of the briefings were being conducted effectively.
The Queensland Network Rules and Procedures did not provide sufficient guidance for rail safety workers to ensure they used standardised rail-specific terminology when communicating safety-critical information.
The training provider, contracted by the operator to conduct Boeing 737 conversion training, was training pilots to flare at 30 ft rather than the manufacturer’s requirement of 20 ft. This increased the risk of unstable and/or hard landings.
The Australian Antarctic Division's pre-charter due diligence arrangements were ineffective at accurately assessing the suitability and level of preparedness of MPV Everest, its crew and its safety management system for operations in Antarctica.
MPV Everest's safety management system (SMS) was neither sufficiently mature for its operations nor had it been implemented effectively or consistently on board the ship at the time of the fire. Further, safety oversight by Fox Offshore, the ship’s managers, had not been effective in monitoring and ensuring compliance with the SMS.
MPV Everest’s managers at the time of the fire, Fox Offshore, had not ensured that the ship was adequately manned, equipped or prepared for the hazards of operations in the Southern Ocean and Antarctica.
Bureau Veritas’ (the classification society responsible) design approval processes had not identified any potential risks associated with the positioning of the fuel oil settling tank air vent pipe termination within MPV Everest's engine room ventilation casing. Consequently, it approved this design and siting of the air vent pipe that, in concert with other contributing factors, resulted in overflowing fuel from the pipe being directly introduced into the ship’s machinery spaces.
Inconsistent, incorrect or missing information related to aspects of MPV Everest’s water mist fixed fire-extinguishing system, including the spaces covered by the system and its design/operation, in multiple ship’s documents increased the risk of the crew incorrectly responding to a fire.
The engine room water mist fixed fire-extinguishing system on board MPV Everest was incorrectly installed. This increased the risk of an ineffective response in the event of a bilge fire.
Electrical enclosures in MPV Everest's engine rooms allowed the ingress of fuel into the enclosures and did not meet the responsible classification society fluid ingress protection standards intended to reduce the associated risk of harmful effects and damage.
While fire drills conducted on board MPV Everest exceeded the minimum number required by regulations, none practised an engine room fire, nor was there was any evidence of onboard training and instruction being provided in the use of the engine room water mist fixed fire‑extinguishing system. Consequently, several crew members were unfamiliar with the operation of the system and opportunities to evaluate the ship's emergency preparedness and remedy areas in need of improvement were lost.
Helibrook’s approved safety management system was not being used to systematically identify and manage operational hazards. As a result, risks associated with conducting human external cargo operations such as carriage of the egg collector above a survivable fall height were not adequately addressed.
Response by Helibrook
The Civil Aviation Safety Authority (CASA) did not have an effective process for assuring an authorisation would be unlikely to have an adverse effect on safety. As a result, CASA delegates did not use the available structured risk management process to identify and assess the risks, ensure appropriate and adequate mitigations were included as conditions of the approval, or assess the effects of changes on the overall risk.
There was no formal interface agreement between Queensland Rail and the Brisbane City Council to jointly identify and manage ongoing and changing safety risks at the road and rail Interface.
Queensland Rail had insufficient resources available to assess all 1,138 public level crossings at 5 yearly intervals or sooner as required by its level crossing safety Standard, with only one person qualified to conduct level crossing safety assessments.
Although Queensland Rail’s internal standard required safety assessments of each public level crossing at least every 5 years, there had been no review or assessment of the Kianawah Road and other level crossings since 2001–2002.
Contrary to the relevant Australian Standard, there was a 3.1 m gap between the tip of the lowered boom barrier and the median island on the northern side of the Kianawah Road level crossing. With the turn line markings directing traffic towards the gap, this increased the risk of road users turning right from Lindum Road and bypassing the boom barrier while it was active.
