Operator’s processes for reviewing its operations

There were a significant number and variety of problems associated with the operator’s activities that increased safety risk, and the operator’s chief pilot held all the key positions within the operator’s organisation and conducted most of the operator’s flights. Overall, there were no effective mechanisms in place to regularly and independently review the suitability of the operator’s activities, which enabled flight operations to deviate from relevant standards.

Following the accident, the operator ceased flight operations. Some of the regulatory changes being introduced under Civil Aviation Safety Regulation (CASR) Part 119 and Part 135 may also help address these types of issues in some small passenger transport operators (see Additional safety action).