Recommendations in CASA guidance CAAP 92-1(1) requiring obstacle clearance out to 900 m may lead to circumstances where ALAs meet these requirements however, aircraft are required to manoeuvre below a safe height or be unable to outclimb rising terrain after take-off more than 900 m past the runway end.
The CASA sample operations manual used by the operator that allowed any aerodrome in the Enroute Supplement Australia to be used for flight training did not assure that these aerodromes were suitable for use.
Response by Civil Aviation Safety Authority (CASA)
On 23 January 2023, CASA provided the following response with respect to this safety issue.
Network Aviation did not include the threat of unforecast weather below landing minima in their controlled flight into terrain risk assessments. This increased the risk that controls required to manage this threat would not be developed, monitored, and reviewed at a management level.
Network Aviation did not provide their flight crew with a diversion decision-making procedure for the circumstances where their flights encountered unforecast weather below landing minima. This increased the risk that their flight crew would not anticipate and be adequately prepared for a diversion.
The illumination of the joystick steering panel’s ‘joystick on’ light indicated which panel was selected (or last selected) for use and bore no relation to the steering mode selected. This increased risk as it was misleading and contrary to the understanding of the ship’s officers who believed that the illumination of the light was only possible when the joystick steering mode was selected.
Neither the master nor the second mate had undertaken required bridge resource management training. This probably contributed to the ineffective implementation of bridge resource management on board, which resulted in the single person errors that contributed to this accident not being detected.
The mitigations introduced by Airbus to counter the design limitation associated with the A330 cabin pressure control systems were ineffective, because:
Response by Airbus
The operator’s training system did not adequately cover the unique requirements of the CAB PR EXCESS CAB ALT alert procedure, increasing the risk of an incorrect or delayed application of the required procedure.
The aircraft was not fitted nor required to be fitted with a crash-resistant fuel system under the current standards or those in place at the time of manufacture. As a result, post-impact fire presents a significant risk of fire-related injuries and fatalities to aircraft occupants.
Response by the United States Federal Aviation Administration
The Federal Aviation Administration is forming a cross-organisational team to review the topic of post-crash fires and identify potential risk mitigations.
The DEENA 7 standard instrument departure has no designed positive separation method, making it susceptible to loss of separation occurrences.
The DEENA 7 standard instrument departure has no designed positive separation method, making it susceptible to loss of separation occurrences.
The surveillance flight information service (SFIS) had been implemented in an area with known surveillance coverage limitations, resulting in the SFIS controller having no displayed positional information for the Caravan until it reached an altitude of about 1,500 feet. Therefore, during the period of conflict between the Caravan and B737, the controller was solely reliant on radio communications for situation awareness, reducing their ability to provide appropriate traffic and avoidance advice.
The eTAP system, used at Track Occupancy Authority (TOA) fulfilment, did not include a key safeworking requirement contained in the ARTC Network Rule ANGE 204 for confirming and repeating back safety critical information.
ARTC will undertake a review of the relevant Rules and Procedures applicable to TOA Fulfilment being ANWT 304 and ANPR 701, including ANGE 204.
The eTAP roll out did not include an effective training regime, as the briefing was not targeted to the appropriate level of competence of the trainees. The Protection Officer involved was not trained or competent in the rules and procedures for Track Occupancy Authority (TOA) at the time of the eTAP briefing. There was no competence assessment for the use of the application for the Protection Officer involved.
Failure of the inboard programming roller cartridge was due to undetected fatigue cracking that occurred in an area that was not included in the detailed flap actuation system inspection.
On board routine inspection and maintenance of fixed cargo securing devices on APL England was ineffective. Over an extended period of time, the significant proportion of the devices that were unfit for purpose were not identified and made good.
A significant proportion of the fixed cargo securing devices on the deck of APL England were in poor condition. The heavy wastage of the devices significantly reduced their load carrying capacity and compromised the effective securing of cargo.
The insecure loading of high cube containers into bay 62 was contrary to the ship's cargo securing manual and not identifiable by the cargo computer software in use at the time. Consequently, forces generated during the heavy rolling resulted in dislodging of all containers above the cell guides and the loss of 16 overboard.
Sydney Trains Signaller refresher training, to keep signallers’ skills and knowledge up to date, has not been in place since 2009.
Sydney Trains assurance and audit processes for signal box management did not routinely detect non-conformances with NTR 432.
