The official investigation into a Link Airways flight where an outside strap broke into the cabin causing a hole has criticised "complacency" at the airport.
After the flight in 2022 took off, the plane was in the air for ten minutes with passengers screaming in terror before it landed to be met by emergency services on the runway.
The Australian Transport Safety Board criticised the Swissport company which deals with on-the-tarmac handling of aircraft. It also indicated that having different companies at the airport - each with different roles - can cause problems.
"When there are multiple risk controls in place and multiple responsible parties, it is easy to become complacent from an expectation that earlier checks have been done correctly and that future checks elsewhere in the system will likely catch anything missed," ATSB chief commissioner Angus Mitchell said.
"The use of external ground handling services has become increasingly common in aviation, and the relationship between a carrier and a ground handler can add complexity to ground handling operations," he said.
"It is critical that all involved parties have a complete understanding of their roles and responsibilities, and how they fit together to create a safe and functional operating environment."
The ATSB said that Canberra-based Link had since "amended training guidance to Swissport, including more details on the use of propeller straps and extensions, as well as the dispatcher's role in checking for the strap.
"And Swissport has informed all ramp staff, including dispatchers and trainers, that walkarounds are required on Saab aircraft, and is examining the potential to include more guidance for its auditors to assess specific task elements. It also consulted with Link to better define dispatcher responsibilities and expectations."
At the time, there was terror in the cabin when the hole in the fuselage appeared.
"We took off and there was a huge, loud bang, and stuff flew over the cabin, and everybody screamed," Carolyn Paisley-Dew, who was in 7A, five seats behind impact, said.
A strap from the propeller had flown into the side of the aircraft as it accelerated down the runway. The strap went through the casing and hit a woman in seat 2A, according to passengers immediately behind her.
Once in the air, with the hole in the side, the Saab 340B circled north over Mount Majura and turned south over Queanbeyan and Jerrabomberra before making the emergency landing.
As the plane came to a stop on the runway, emergency services rushed across the tarmac and entered the aircraft.
The passenger in window seat 2A was treated for injuries to her face, according to Ash Atkinson who was in seat 6A.
A passenger across the aisle from the impact said: "It was as loud as a bomb going off."
