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07 May 2005 Controlled Collision of Aircraft VH-TFU into Terrain.…

- - - - 1.7.3. Captain had just returned from holiday(Australian Transport Safety Bureau 2007, p. 14).
      - 1.7.1.. Captain flew 176hrs in previous 90 days (Australian Transport Safety Bureau 2007, p. 10).
      - 1.7.2. Co-pilot flew 150 hrs in previous 90 days (Australian Transport Safety Bureau 2007, p. 15).
      - 1.7.4. This flight was the Co-pilots 5th duty day (Australian Transport Safety Bureau 2007, p. 15).
    - - 1.8.1. Co-pilot age 21 (Australian Transport Safety Bureau 2007, p. 15).
      - 1.8.2. Captain age 40(Australian Transport Safety Bureau 2007, p.9).
    - - 1.5.2. Transair’s chief pilot was also a shareholder and director of Trans Air Limited operating in Papua New Guinea (Australian Transport Safety Bureau 2007, p. 73). Was there a financial reason the chief pilot turned a blind eye to all of Transairs regulatory breeches?
        
        1.5.2.3. The chief pilot was stretched too thin 'was doing 4 different jobs (Office of the State Coroner 2007, p. 35). Was there a financial reason why more staff were not engaged, or did the chief pilot not understand a safety specialist needed to be engaged as a stand alone position?
        
        1.5.2.4. The chief pilot failed to monitor review or enforce the safe flying practices of its pilots (Office of the State Coroner 2007, p. 39).Was the chief pilot even aware pilots were flying unsafely. What was it about the reporting culture that did not encourage speaking up for safety?
        
        1.5.2.5. Key safety personnel had too many duties and were overworked. (Office of the State Coroner 2007, p. 46). What was neglected within the system that contributed to this event? .
        
        1.5.2.1.The captain and chief pilot each had differing opinions on how things should be done (Office of the State Coroner 2007, p. 38).
        
        1.5.2.2. The chief pilot was seen to be passive, not rigorous, systematic or proactive (Office of the State Coroner 2007, p 38).
      - 1.5.1. What was wrong with the safety system where there was no incentive within Transair to report safety concerns with management? (Australian Transport Safety Bureau 2007, p. xv).
      - 1.5.4. Two pilots stated that they did not bother reporting flight operational hazards because they learnt through experience that nothing would change as a result. What was wrong with the reporting system that allowed pilots to hold this opinion that reporting wasa waste of time? Were they punished for reporting? (Australian Transport Safety Bureau 2007, p. 106).
      - 1.5.3. Captain historically had a habit of flying aircrtaft too fast especially during approach (Office of the State Coroner 2007, p.31). Why wasn't this reported? Why was the captain allowed to fly even after numerous breeches of SOP's
        
        1.5.3.1. Captain believed his seniority gave him authority to make illegal decisions (Office of the State Coroner 2007, p. 27).
        
        1.5.3.2. The operator did nothing to discourage illegal pilot conduct (Office of the State Coroner 2007, p. 27)
    - - 1.9.1. Co-pilot struggled when under pressure (Australian Transport Safety Bureau 2007, p. 18). What pressures were identified, that created this stress? Was it his inexperience or the pilot that was at fault?
      - 1.9.2. Why did the maintenance controller also hold the position of safety manager, when the controller reported that he felt ‘a bit stretched’ with the workload associated with the two positions? (Australian Transport Safety Bureau 2007, p. 76).
      - 1.9.3. Transair pilots reported that they did not consider there was any commercial pressure to keep to the published schedule for the RPT services (Australian Transport Safety Bureau 2007, p. 77). Was this actually the case, or were they just saying this to keep out of trouble? What was Transairs actual financial position? Did CASA know what the financial position was?
    - - 1.2.2. Co-pilots attention focused on radio transmissions during approach to LHR (Australian Transport Safety Bureau 2007, p. xiii). Why only radio transmissions? What about not hitting the ground?
      - 1.2.1. Captain task focused on GNSS (Australian Transport Safety Bureau 2007, p. xiii). What role did the co-pilot have in flying the aircraft. What was his state of attention?
      - 1.2.3. Descent speeds, approach speeds and rate of descent all exceeded Transair Operations Manual for the approach (Australian Transport Safety Bureau 2007, p. 187).
        
        1.2.3.2. False perception a continued descent below minimum safe altitude would see visibility improve (Office of the State Coroner 2007, p. 29). Was this secretly encouraged within the organisation, or was it only this pilot that tried to shoot for the hole?
        
        1.2.3.1. Captain flew excessively fast, would not follow SOP's and would rush procedures (Office of the State Coroner 2007, p. 31). Why was this continuing behaviour allowed?
    - - 1.4.1. What in the Transair culture allowed for the co-pilot to defer to Captains actions and not criticize poor decisions? (Australian Transport Safety Bureau 2007, p. 19).
        
        1.4.1.2. Why did the endorsement training provided to either pilot not include operating the aircraft in a multi-crew environment? (Australian Transport Safety Bureau 2007, p. 204).
        
        1.4.1.3. There was a high trans-cockpit authority gradient and neither pilot had previously demonstrated a high level of crew resource management skills. (Australian Transport Safety Bureau 2007, p. 237).Why wasn't there mandatory CRM carried out, and what role did CASA have in ensuring mandatory training was carried out and reported?
        
        1.4.1.4. The very Junior co-pilot apparently deferred to the Captain to allow a GNSS approach to be made, even though an IMC compliant landing was extremely unlikely (Office of the State Coroner 2007, p. 27). What was the culture that allowed the captain to do what he wanted, even though his actions were a deliberate violation of aviation safety rules?
    - - 1.3.1. Why was the co-pilot not GNSS trained (Australian Transport Safety Bureau 2007, p. 17).
      - 1.3.6. Co-pilot failed his aircraft engineering test (Australian Transport Safety Bureau 2007, p. 15.). This goes to experience. What systems were in place for retesting? Could he still fly? What was the CASA guidelines for this situation?
      - 1.3.3. Co-pilot inexperienced with 655 hrs flight time (Australian Transport Safety Bureau 2007, p. 15).
      - 1.3.4. Captain was an experienced pilot. 3428hrs flight time on type (Australian Transport Safety Bureau 2007, p. 9).
      - 1.3.5.. Co-pilot struggled when under pressure (Australian Transport Safety Bureau 2007, p. 18).
      - 1.3.2. Why was there no CTIF training carried out? (Australian Transport Safety Bureau 2007, p. 41).What were the requirements for this aircrew training?
    - - 1.6.1. No trace of illicit substances in Captain or Co-pilot (Australian Transport Safety Bureau 2007, p.14 & 65).
      - 1.6.2. No health or medical issues identified in Captain or Co-pilot (Australian Transport Safety Bureau 2007, p. 14 & 65).
- - - - 3.1.5.6. Why was there no CASA record for the installation of GPWS when the aircraft was granted its' airworthiness certificate (Australian Transport Safety Bureau 2007, p. 31).
      - 3.1.5.7. Why did the co-pilots over recording of his IMC flights in his logbook go unnoticed?(Australian Transport Safety Bureau 2007, p.16).
      - 3.1.5.2. The Transair Operations Manual was provided to pilots on a CD-ROM (Australian Transport Safety Bureau 2007, p. 80).
      - 3.1.5.1.Pilots had to reprint the entire manual every time an amended CD-ROM was received (Australian Transport Safety Bureau 2007, p. 81).Would this be a reason pilots just did not bother? Everytime there was a change on the CD, the entire publication would need to be printed.
      - 3.1.5.3. All pilots needed RNAV (GNSS) approach endorsements as this was the only instrument approach available into Bamaga. Why was their no evidence that this issue was ever risk-assessed in a formal way? (Office of the State Coroner 2007, p. 36).
        
        3.1.5.3.1. Both pilots were endorsed for the NDB approach, and therefore that approach was the only one available to the crew when IMC (Australian Transport Safety Bureau 2007, p.189).
        
        3.1.5.3.2. No formal requirement in HARM for a formal risk assessment of GNSS ops or pilot endorsements for GNSS use. (Office of the State Coroner 2007, p. 36).
      - 3.1.5.5. Why was there no mechanism in place to ensure all audit reports were sent to CASA management? (Australian Transport Safety Bureau 2007, p. 116).
      - 3.1.5.4.Why was it the Hazard and Risk Management (HARM) data base was only used for reporting of maintenance issues and incidents, not safety issues? (Office of the State Coroner 2007, p. 36).
        
        3.1.5.3.3. No records were kept of any disciplinary or counselling action taken against pilots. (Office of the State Coroner 2007, p. 39).
    - - 3.1.2.1. Captains communication style in the cockpit was reported as being direct (Australian Transport Safety Bureau 2007, p. 19).
    - - 3.1.4.2. Crucial aircraft handling data was missing from the operations manual (Australian Transport Safety Bureau 2007, p. 88). Where was the information, and who had the responsibility for ensuring it was entered? Did they even know this data was missing?
        
        3.1.4.2.1.Why did the Operations manual have no guidance on how to accomplish a stabilised approach? Why was the role of pilots in a multi crew environment not detailed?. (Office of the State Coroner 2007, p. 39).
        
        3.1.4.2.2. Why was there was no approach configuration for the Metro in the manual? (Office of the State Coroner 2007, p. 39).
      - 3.1.4.3.Design aspects of the RNAV (GNSS) approach charts, could lead to pilot confusion or a reduction in situational awareness. Why did Jeppeson allow poorly designed charts to be provided? Did Jeppeson know about pilot confusion as a result of using these maps? (Australian Transport Safety Bureau 2007, p. xv).
      - 3.1.4.1. Why was there no SOP for pilots flying into LHR. Was Transair aware their pilots used their own judgement when landing at LHR? (Office of the State Coroner 2007, p. 39).
    - - 3.1.1.3. Why was there no record either pilot had completed the Human Factors Management Induction Course or any Human Factors Management recurrent training course? (Australian Transport Safety Bureau 2007, p. 96).
      - 3.1.1.4. Why did Transair pilots have to arrange their own RNAV (GNSS) endorsement training? Why didn't the company provide this training? Why didn't Transair track pilot recency for RNAV (GNSS) approaches? (Australian Transport Safety Bureau 2007, p. 97.)
      - 3.1.1.2. Check pilot commented endorsement training provided by Transair was basic, the standard of endorsed pilots was barely adequate, and no consolidation training was provided following the endorsement (Australian Transport Safety Bureau 2007, p. 93). Why was nothing done with these findings?
      - 3.1.1.5. Why was it that a Transair supervisory pilot reported that it was common to spend additional time training new co-pilots when they arrived because they were not sufficiently trained during the endorsement process to carry out the role and functions of a co-pilot? What training did they actually receive? (Australian Transport Safety Bureau 2007, p. 94).
      - 3.1.1.6.Why was there was no ongoing training or checking? (Office of the State Coroner 2007, p.26).
        
        3.1.1.6.1. Why did Transair not carry out all of the GNSS proficiency checks on Captain? (Office of the State Coroner 2007, p. 40).
      - 3.1.1.1.Why were training and checking requirements contained in disparate regulatory resources and publications? (Office of the State Coroner 2007, p. 48).
    - - 3.1.3.4. CD ROM format for Operation Manual was extremely difficult to use. Pilots often did not even read manual. Why was no other form of publication made available for the pilots to use? (Australian Transport Safety Bureau 2007, p. 80).
      - 3.1.3.5.The FAA identified human factors issues identified for GPS receivers were mostly the result of the large number of possible functions with a small number of buttons and knobs, and a small display screen. Why wasn't this data displayed on the HSI? (Australian Transport Safety Bureau 2007, p.157).
      - 3.1.3.2. No hyperlinks in manual. This should have been an easy administrative fix so why wasn't this done? (Australian Transport Safety Bureau 2007, p. 80).
      - 3.1.3.1. CASA inspector stated the CD-ROM format of the Transair Operations Manual to be not useable. Why did CASA still allow the use of this manual if it was unusable by the pilots? (Australian Transport Safety Bureau 2007, p. 81).
      - 3.1.3.3. RNAV (GNSS) approaches were relatively new at the time of the accident, both in Australia and internationally, so why wasn't more training enforced? (Australian Transport Safety Bureau 2007, p. 156).
  - - - See task overload.
    - - 3.2.1.1. Maintenance control process deficiencies included poor documentation control, lack of detail on avionic inspection procedures, the absence of a deferred maintenance procedure and incomplete records of on-aircraft components (Australian Transport Safety Bureau 2007, p. 106).Were these processes ever audited, and if so, why weren't any changes made?
        
        3.2.1.2. 22 Unlawful landings into LHR (Office of the State Coroner 2007, p.15).
        
        3.2.1.3. The pilots were not authorised to fly RPT operations, so what was the reason the company turned a blind eye to this and allowed flying to continue? (Office of the State Coroner 2007, p. 15).
    - - 3.2.2.1.4..Why hadn't the co-pilot been provided with any crew resource management training?(Australian Transport Safety Bureau 2007, p. 16).
      - 3.2.2.1. Why was the co-pilot, who was not checked by a check pilot prior to commencing line operation, allowed to fly? (Australian Transport Safety Bureau 2007, p. 16).
        
        3.2.2.1.2..Why did the chief pilot conduct line checks but did not discuss the operational standards? (Office of the State Coroner 2007, p. 34). Who was checking the chief pilot?
        
        3.2.2.1.3.. Chief pilot did not observe the conduct of regular line operations (Office of the State Coroner 2007, p.34).
        
        3.2.2.1.1.. Chief pilot was not aware pilots were doing GNSS approaches unendorsed (Office of the State Coroner 2007, p. 34).The chief pilot must have known unendorsed pilots were doing these approaches, as landing at Bamaga required this type of approach.
  - - - 3.7.3. There was no formal training for new pilots in the operational use of global positioning system (GPS) equipment (Australian Transport Safety Bureau 2007, p. xiv). Was this requirement on a training matrix, and if not, why not?
      - 3.7.5. There was no structured training on minimising the risk of controlled flight into terrain (Australian Transport Safety Bureau 2007, p. xiv). Why was no training carried out? Should this also have been a CASA mandatory training, and if so what processes did CASA have for ensuring this was carried out?
      - 3.7.2. The flight crew training program was superficial and ground-based instruction during endorsement training was incomplete (Australian Transport Safety Bureau 2007, p. xiv). Who should have been ensuring all training was carried out and was complete? Was this internal, or should have external providers have been used?.
      - 3.7.6. No structured training in crew resource management (or human factors management) and operating effectively in a multi-crew environment (Australian Transport Safety Bureau 2007, p. xiv).
      - 3.7.4. An independent approved check pilot was not used to review operations. (Australian Transport Safety Bureau 2007, p. xiv). Should this have been a CASA requirement?
      - 3.7.1. Why was it when the chief pilot reported that there was no risk assessment for the introduction of RPT services into Lockhart River they weren't carried out? See something, do something.(Australian Transport Safety Bureau 2007, p. 106).
    - - 3.5.2. Why was there no SOP guidance for conducting instrument approaches and no clear guidance on approach speed? (Australian Transport Safety Bureau 2007, p. xiv).
        
        3.5.2.1. Why was it that the GNSS approach was not in operations manual. Both pilots should have known this approach could not be lawfully conducted, yet they still flew this approach? (Office of the State Coroner 2007, p. 26).
      - 3.5.1. Why did the SOP not provide guidance on selecting aircraft configuration changes during an approach? (Australian Transport Safety Bureau 2007, p. xiv).
      - 3.5.5.Why was there no clear criteria for a stabilised approach? (Australian Transport Safety Bureau 2007, p. xiv).
      - 3.5.6.Why was there no standardised phraseology for challenging safety-critical decisions and actions by other crew member? (Australian Transport Safety Bureau 2007, p. xv).
      - 3.5.3. Why was there no structured process within Transair for proactively managing safety-related risk associated with its flight operations? (Australian Transport Safety Bureau 2007, p. xv).
        
        3.5.3.2. Why was there no guidance provided in the Surveillance Procedures Manual regarding how to evaluate the quality of an organisation’s processes to identify hazards and analyse risk? (Australian Transport Safety Bureau 2007, p. 133).
        
        3.5.3.4. Why did the safety system not provide adequate guidance or oversight of flying activities? (Office of the State Coroner 2007, p. 26).
        
        3.5.3.3. The safety management system systems for corporate management , control and communication were inadequate, yet there was no oversight that would have enforced continual improvement. (Office of the State Coroner 2007, p. 35).What were the CASA requirements for operators to have oversight?
        
        3.5.3.3.3. Why was the safety management system not correctly documented?(Office of the State Coroner 2007, p. 35).
        
        3.5.3.3.4. T chief pilot did not carry ot a task analysis to ascertain number of check pilots needed. (Office of the State Coroner 2007, p. 37). What was the CASA requirement for these numbers, and what evidence was available to make this determination?
        
        3.5.3.3.2. Pilots did not hold instructor ratings when doing this job (Office of the State Coroner 2007, p. 37). What oversight did CASA have regarding instructor ratings, and associated evidence?
        
        3.5.3.3.5. Cairns Base manager had no prior training or instructor experience before being appointed to the position (Office of the State Coroner 2007, p. 37).Was this a requirement to have an aviation background, and was he suitable for the task?
        
        3.5.3.3.1. Pilots has been approved as check pilots without their knowledge (Office of the State Coroner 2007, p. 37). What oversight did CASA have regarding check pilot certification?
        
        3.5.3.3.6. Why were there no multi crew procedures training provided for aircraft endorsement? (Office of the State Coroner 2007, p. 37).Why was the pilot and co-pilot allowed to fly without this training?
        
        3.5.3.3.6.8. Level of training provided to pilots during endorsement was not sufficient (Office of the State Coroner 2007, p. 37). What extra training was required to meet the proficiency, and was this independently verified or carried out in house?
        
        3.5.3.3.6.9. How were the captain and co-pilot able to fly when they had not been line checked by a check pilot before commencing duties as a crew member on a scheduled revenue service? (Office of the State Coroner 2007, p. 37). Was CASA notified, and was there a requirement for CASA to be informed?
        
        3.5.3.3.7.0. Mandatory crew resource management training not provided as part of Transairs human factors management (Office of the State Coroner 2007, p. 37).
        
        3.5.3.3.67.1. At the time of the accident there was no mandatory requirement to implement safety management systems or CRM training (Office of the State Coroner 2007, p. 46). Did CASA have a reason for this not to be mandatory?
        
        3.5.3.3.6.7. Why did the operations manual only provided brief guidance on GPWS warnings, and why was there was no training syllabus for the GPWS? (Office of the State Coroner 2007, p. 38).
        
        3.5.3.1. There were no annual safety audits carried out on Transairs bases iaw safety manual (Office of the State Coroner 2007, p. 36). How was it that CASA did not follow up on this and require these audits to be carried out?
      - 3.5.7. Why was there no training syllabus for CFIT training? (Australian Transport Safety Bureau 2007, p. 41).Why didn't CASA provide this generic but critical training syllabus?
        
        3.5.7.1. Why was there no specified program for the ongoing development of pilots, and no evidence that any such training had been provided?(Australian Transport Safety Bureau 2007, p.211). Was there a training matrix, who was responsible for it and how did so many pilots be allowed to fly with so much outstanding training
        
        3.5.7.2. 1999 was the last time any pilot had viewed the CFIT video. (Office of the State Coroner 2007, p. 38).Were pilots even aware this was mandatory, and if so, why did only one pilot ever complete this training?
      - 3.5.4. Why was there was no specified process for monitoring the effectiveness of supervisory pilots? (Australian Transport Safety Bureau 2007, p. 211).
    - - 3.4.2. There was no defined processes for selecting and monitoring the performance of the Cairns Manager (Captain) (Australian Transport Safety Bureau 2007, p. xiv). Was ad-hoc employment the best way to go. What experience was required?
      - 3.4.3. Limited responsibilities were given to non-management personnel, and this has resulted in high work demands on the Transair chief pilot. (Australian Transport Safety Bureau 2007, p. xv).
      - 3.4.1.Why was there only reliance on passive measures to detect problems? (Australian Transport Safety Bureau 2007, p. xiv). Why weren't more active reporting measures encouraged? Was there a penalty for reporting?
      - 3.4.4. No evidence Transair pressured pilots to carry out any non authorised procedures (Office of the State Coroner 2007, p. 27). Why is it that so many non authorised procedures were allowed to be carried out by pilots? Why was this evidence not acted upon?
    - - 3.6.6. Why was there no CASA requirement for operators to conduct structured or comprehensive risk assessments when evaluating applications for the initial issue of Air Operator’s Certificate? (Australian Transport Safety Bureau 2007, p. xv).
        
        3.6.6.2. CASA did not carry out a risk assessment for public transport service into LHR (Office of the State Coroner 2007, p. 36). What role did CASA have and why was this missed by the regulator?
        
        3.6.6.3. No evidence CASA ever reviewed Transairs operations manual in relation to CRM training (Office of the State Coroner 2007, p. 36).What role did CASA have and why was this missed by the regulator?
        
        3.6.6.1. Why were Transairs SOP's not reviewed for passenger services? (Office of the State Coroner 2007, p. 36). What role did CASA have and why was this missed by the regulator?
        
        3.6.6.4.. CASA did not require a safety case from Transair when they applied for a public transport route into LHR (Office of the State Coroner 2007, p. 45).What role did CASA have and why was this missed by the regulator?
      - 3.6.4. Why was there no regulatory requirement for instrument approach charts to include coloured contours to depict terrain as required by ICAO? (Australian Transport Safety Bureau 2007, p. xv). Why did CASA still allow these charts to be used?
        
        3.6.4.1.Why was the LHR GNSS approach compromised? Why were the parameters that did not align with ICAO requirements allowed? (Office of the State Coroner 2007, p.17).
        
        3.6.4.2.Why would CASA downplay the necessity for instrument approaches, and suggested VFR only operations were feasible? What evidence did CASA have to back this up? (Office of the State Coroner 2007, p. 34).
      - 3.6.1. Why did CASA did not provide sufficient guidance to its inspectors to enable them to effectively evaluate operators’ management system? (Australian Transport Safety Bureau 2007, p. xv).
        
        3.6.1.1.. CASA inspectors received a 5-day introductory training course on human factors (Australian Transport Safety Bureau 2007, p. 117). Was this a sufficient enough time period to ensure they could carry out their required tasks? What previous experience did they have?
        
        3.6.1.4. CASA inspectors reported that they experienced high workloads meeting the requirements of conducting two scheduled audits per year (Australian Transport Safety Bureau 2007, p. 119). Did CASA do anything with these reports? Did they investigate the reasons behind the extreme workloads and put measures into place?
        
        3.6.1.4.1. CASA auditing was discontinuous, poorly resourced and often done by only one person (Office of the State Coroner 2007, p. 45).Why only one person? Was there peer review of results, and were they independently verified for reliability?
        
        3.6.1.4.2.. CASA's risk assessment tool for auditing survelence activities was poorly developed (Office of the State Coroner 2007, p. 45).What tool was used, and was it fit for purpose? Why weren't the safety concerns identified actioned, or were they even identified?
        
        3.6.1.2. Why didn't the regulator carry out its due diligence? It could have confirmed GNSS operations were being carried out by non qualified pilots by checking BOM reports at LHR (Office of the State Coroner 2007, p. 35).
        
        3.6.1.3. What was wrong with CASA procedures that when surveillance of Transair was carried out, it did not detect that line and base checks had been carried out by pilots not authorised to? (Office of the State Coroner 2007, p. 44).
      - 3.6.2. Why was there no regulatory requirement for initial or recurrent crew resource management (CRM) training or for RPT operators to have a safety management system? (Australian Transport Safety Bureau 2007, p. xv).
      - 3.6.3. Why was there no regulatory requirement for multi-crew RPT aircraft to be fitted with a serviceable autopilot? (Australian Transport Safety Bureau 2007, p. xv).
      - 3.6.5. What reasons did the aviation safety regulator have for not responding adequately to the information available to it, when a deficiency in training and safety system was indicated? (Office of the State Coroner 2007, p. 26).
- - - - 2.2.4.1. Cockpit Voice Recorder inoperative (Australian Transport Safety Bureau 2007, p. xiv). Why was the aircraft allowed to fly with this unserviceability, and were the aircrew even aware the CVR did not work?
    - - 2.2.5.3. GPS satellite navigation system informationwas the primary means of positional situational awareness information during an RNAV (GNSS) approach (Australian Transport Safety Bureau 2007 p. 24).
        
        2.2.5.4..Captain had previously deactivated the GPWS alerts on previous flights. These warnings would have warned of an impact (Office of the State Coroner 2007, p. 30).Why were the system alerts able to be turned off?
        
        2.2.5.5.The GPWS fitted to the aircraft could alert spuriously even when flying the correct route. This could, in IMC force the pilot to abandon the approach, or even just ignore the warning (Office of the State Coroner 2007, p. 52). Why would the pilot continue his descent when the GPWS was alerting him to danger? Was this common practice?
      - 2.2.5.6. No system maintenance tests carried out for GPWS. Self tests carried out only (Australian Transport Safety Bureau 2007, p. 30-31)
      - 2.2.5.1. No maintenance interval called out for GPWS by aircraft manufacturer (Australian Transport Safety Bureau 2007, p.30). What was the CASA requirement?
      - 2.2.5.7. No TAWS fitted (Australian Transport Safety Bureau 2007, p. xiv & p. 38).
        
        2.2.5.8. Mandatory requirement for TAWS to be fitted was delayed 4 1/2 years. The TAWS should have been fitted (Office of the State Coroner 2007, p. 49). How was this even possible? The aircraft should have been grounded by CASA until the terrain avoidance system was fitted.
      - 2.2.5.2. Altitude alerter signals ignored (Office of the State Coroner 2007, p. 30). Why would this happen? Why didn't the co-pilot alert the captain?
    - - 2.2.2.1. Four sources of aircraft information that could have potentially alerted the crew to the developing problem: altimeters, vertical speed indicators, radio altimeter and the GPWS (Australian Transport Safety Bureau 2007, p. 195). Why was the GNSS used as the sole navigation aid?
    - - 2.2.1.3. Radio altimeter system (Australian Transport Safety Bureau 2007, p.26).
      - 2.2.1.4. Altitude alerting system (Australian Transport Safety Bureau 2007, p.27).
      - 2.2.1.2.Vertical speed indicators (Australian Transport Safety Bureau 2007, p.26).
      - 2.2.1.1 Barometric altimeters (Australian Transport Safety Bureau 2007, p.24).
        
        2.2.1.1.1. Both altimeters had wrong QNH set for LHR (Australian Transport Safety Bureau 2007, p. 61). Was this due to cockpit work overload? What procedures / training was available within Transair to confirm this was not happening amongst every pilot?
      - 2.2.1.5. Ground proximity warning system (Australian Transport Safety Bureau 2007, p.27).
      - 2.2.1.6. Global positioning system (Australian Transport Safety Bureau 2007, p.31).
        
        2.2.1.6.1. GNSS approach used 5 waypoints with 5 letter name, 4 for each. Could be confusing. (Office of the State Coroner 2007, p.17). Was there a better system available? Why was it so unergonomic in use. Did the manufacturer realise how difficult it was for pilots to use?
    - - 2.2.6.2. GPS difficult to see when aircraft in turbulence (Australian Transport Safety Bureau 2007, p 35).
      - 2.2.6.3. No autopilot fitted. (Australian Transport Safety Bureau 2007, p. 38).Was there a CASA requirement for one to be fitted?
      - 2.2.6.1. The Jeppeson chart in use for LHR was confusing as distance to threshold and missed approach point were not coincidental, as it is in most countries' (Office of the State Coroner 2007, p. 51).
        
        2.2.6.1.1. The Jeppesen chart had an offset distance that is not in use for other countries (Office of the State Coroner 2007, p. 51). Did CASA know these charts did not conform?
    - - 2.2.3.1. GPWS cockpit annunciators and switches were installed in the wrong location within cockpit (Australian Transport Safety Bureau 2007, p. 35). Where was the maintenance oversight. Were the engineers self certifying?
  - - - 2.3.5.1. Co-pilot was not assertive and would have been out of his comfort zone working with a very direct Captain.(Australian Transport Safety Bureau 2007, p. 19).
    - - See PEOPLE, Individual Factors.
    - - 2.3.1.1. Why would any aural GPWS warnings not have been heard in a task overload situation.(Australian Transport Safety Bureau 2007, p. 197). What role did the captain play in not reacting to these warnings?
    - - 2.3.6.1. The Co-pilot’s flight instrument lighting was recorded as unserviceable (Australian Transport Safety Bureau 2007, 1.6.15).
    - - 2.3.3.2. Aspects of the approach chart design also added to the potential for pilots to lose situational awareness (Australian Transport Safety Bureau 2007, p. 190.) Why was Jeppeson allowed to produce these charts, and was CASDA aware of the difficulty pilots had using these charts?
      - 2.3.3.3. Compressed time available to fly each segment of the approach due to the higher than specified speeds during the approach (Office of the State Coroner 2007, p. 30). Why was a captain who was known to fly excessively fast, allowed to fly this approach?
        
        2.3.3.6.. The complex nature of the Lockhart River Runway 12 RNAV (GNSS) approach (Australian Transport Safety Bureau 2007, p. 202).
        
        2.3.3.7..No autopilot or vertical altitude advisory resulted in the crew needing to perform more cognitive tasks, as well as the perceptual tasks (Australian Transport Safety Bureau 2007, p. 202).
        
        2.3.3.4.. Why would have there been a loss of situational awareness using GNSS? Would there have been confusion about what segment was flown and how far away from the runway threshold they were? (Office of the State Coroner 2007, p. 18).
        
        2.3.3.5.. Aircraft position could be misinterpreted due to difficulty reading GNSS step down profile (Office of the State Coroner 2007, p. 18). What systems were in place to prevent this error from occurring? Why weren't other available systems in place used?
      - 2.3.3.1. GPS use increased workload for Captain (Australian Transport Safety Bureau 2007, p. 39)
    - - 2.3.2.2. Weather was sub optimal (IMC) for landing at LHR (Australian Transport Safety Bureau 2007, p. 3 & CF p. 18).
      - 2.3.2.1. Why were no calls made by pilots to LHR BOM to check conditions? (Australian Transport Safety Bureau 2007, p. 43). Was this a checklist step missed, or was this common practice?
  - - - 2.1.2.2. Navigation and warning systems relevant to conducting an instrument approach were not in an optimum position for one or both of the crew in VH-TFU.(Australian Transport Safety Bureau 2007, p.207). Why did CASA allow cockpit instruments to be in the wrong position?
      - 2.1.2.1. Pilot in command in left seat, co-pilot in right seat (Australian Transport Safety Bureau 2007, p.24).
    - - 2.1.3.1. NDB was available at LHR, but no attempt was made to use it.(Office of the State Coroner 2007, p. 27). Why was the NDB not used?
    - - 2.1.1.2. Some navigation and warning systems relevant to conducting an instrument approach were not in an optimum position for one or both of the crew (Australian Transport Safety Bureau 2007, p. 207).What ergonomic effects did this have in a high stress situation. Was vital information just not seen?
      - 2.1.1.1 Limited usefulness of the moving map display because of the vertical size of the LCD screen size (Australian Transport Safety Bureau 2007, p. 219). Why was the moving map not used, when it would have provided a perfect picture of the aircrafts position above the terrain?
- - - - CASA grants certificate of airworthiness 04 July 2003 (Australian Transport Safety Bureau 2007, p. 21).
        
        All maintenance and airworthiness directives correctly carried out and certified (Australian Transport Safety Bureau 2007, p. 37).
        
        GPS already fitted prior to purchase under FAA approval (Australian Transport Safety Bureau 2007, p. 31).
        
        Aircraft maintenance release valid until 17 April 2006 (Australian Transport Safety Bureau 2007, p. 22).
        
        At the time of the crash the aircraft had 26 877 AFHRs and 28529 cycles ( Australian Transport Safety Bureau 2007, p. 21).
        
        Aircraft was serviceable at the time of the crash (Australian Transport Safety Bureau 2007, p.37).