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.
The ATSB notes that Network Aviation have taken action to update their controlled flight into terrain risk assessments to capture the threat of adverse weather, which addresses the safety issue.
In response to the draft report, Network Aviation advised that ATSB that:
Through a review conducted by representatives of the Qantas Groups Flight Operations Safety Committee (FOSC) and safety risk specialists in the business a threat line has been added to the Controlled Flight into Terrain (CFIT) Bowtie including both the non-precision and precision approach bowties. The threats and controls were reviewed based on the event and the learnings from that event. As a result, all CFIT bowties have been updated. We have added escalation factors and escalation factor controls to the Visual Reference control on bowtie 3.1. And we have added the “Flt Crew operate below the appropriate minimum altitude (i.e. lowest safe altitude, DA, MDA)” threat line in its entirety to bowties 3.2 and 3.3.