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Human Factors (Peolpe (Expectations (CEO of Whyalla Airlines was known as…

- - - - CEO of Whyalla Airlines was a micro manager of pilots
      - Coroner recognised that CEO was a micro manager his leadership style had pilots on edge fearing repercussions for poor form
    - - ATSB conducted investigation of incident and made findings
      - Aviation experts were very critical of report recognizing obvious flaws in investigation
      - Due to pending legal action the representatives for Textron Lycoming (Engines) would not share all info with the ATSB
      - Coroners inquest ordered. Coroner critical of ATSB investigation
  - - - Witness at airport believed that plane was not refuelled
      - On night of incident at 2130 refueling truck operator could not recall if he refueled the plane
      - Investigation of planes fuel on board suggested the plane had been refueled
      - Refueling truck operator recalled refueling plane at coroners inquest. Coroner suggested truck operators evidence was poor
      - Audits of fuel used suggested plane was refuled
  - - - Pilots were pressured by CEO to meet KPIs for arrivals and departures
      - Pilots would cut corners for pre-flight checks due to pressure to meet KPIs
      - Due to pressure pilots would sometimes take off without being refueled (whether due to pressure or due to forgetting due to priorities confusing decision making
      - Pilots expected to conduct many tasks for turnarounds (check in passengers, safety check of plane, unload bagagge etc) thus leading to time constraint pressures
- - - - Plane not fitted with emergency equipment life rafts / life jackets etc
      - Plane not fitted with flight recorders (and not required at time)
      - ATSB determined that plane engines failed due to oxybromide on pistons, pilot pushing full throttle and thermal crack on number 6 journal
      - Coroners findings determined plane engines failed due to subsurface cracking in the crankshaft of the left engine and the right engine failed due to end gas detonation during the climb phase of the flight
  - - - Flight was during night conditions
      - Weather was overcast with drizzle/rain and southerly breeze
      - Water temp on impact was between 14 - 16 degrees and would have inducted a gasping effect on passengers when contact was made with water thus causing cold shock and swallowing salt water