Batik Air's change management processes were not effective at fully identifying and mitigating the risks associated with the commencement of the Denpasar to Canberra route.
The safety actions taken by Batik Air address the outstanding risks that were not fully identified and mitigated during the Denpasar to Canberra route commencement process. Furthermore, the additional safety action taken provides additional assurance that Batik Air’s route commencement change management processes should effectively identify and mitigate the risks associated with the commencement of new routes.
Batik Air revised the Canberra Airport Briefing document to include detailed information on Canberra air traffic control hours, CTAF procedures, holding requirements and guidance for adherence to lowest safe altitude requirements.
Batik Air also issued an internal notice highlighting the mandatory Risk Management Review (RMR) process for all new routes and other significant operational changes. This notice intends to ensure comprehensive hazard identification, detailed risk assessments and an evaluation of the need for route proving flights or additional crew familiarisation.
