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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2017-005-SI-08Regulatory surveillance – scoping of surveillance events Number: AO-2017-005-SI-08 Description: AO-2017-005-SI-08:The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or ... Who it affects: All operators. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Air transport	Date, status, type Date: 17 Oct 2019 Status: Safety action pending Type: Recommendation
Issue, description, who it affects Issue: AO-2017-005-SI-07 Requirements for briefing the brace position in small aircraft Number: AO-2017-005-SI-07 Description: AO-2017-005-SI-07 :There was no requirement for operators of passenger transport flights in aircraft with six or less seats to provide passengers with a verbal briefing, or written briefing material, on the brace position for an emergency landing or ditching, even for aircraft without upper torso restraints fitted to all passenger seats. Who it affects: All aircraft owners, operators, pilots and passengers of small aeroplanes. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Air transport	Date, status, type Date: 17 Oct 2019 Status: Safety action pending Type: Proactive Action   Proactive Action
Issue, description, who it affects Issue: AO-2017-005-SI-06 Requirements for upper torso restraints in small aircraft Number: AO-2017-005-SI-06 Description: AO-2017-005-SI-06 :Upper torso restraints (UTRs) were not required for all passenger seats for small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992, including for passenger transport operations. Although options for retrofitting UTRs are available for many models of small aircraft, many of these aircraft manufactured before the applicable ... Who it affects: All aircraft owners, operators, pilots and passengers of small aircraft without upper torso restraints for all passenger seats. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Air transport	Date, status, type Date: 17 Oct 2019 Status: Safety action pending Type: Recommendation
Issue, description, who it affects Issue: AO-2017-005-SI-05Operator’s processes for reviewing its operations Number: AO-2017-005-SI-05 Description: AO-2017-005-SI-05:There were a significant number and variety of problems associated with the operator’s activities that increased safety risk, and the operator’s chief pilot held all the key positions within the operator’s organisation and conducted most of the operator’s flights. Overall, there were no effective mechanisms in place to regularly and ... Who it affects: The operator’s pilots and passengers. Issue owner: Wyndham Aviation Pty Ltd Operation affected: Aviation: Air transport	Date, status, type Date: 17 Oct 2019 Status: No longer relevant
Issue, description, who it affects Issue: AO-2017-005-SI-04Operator’s conduct of near-aerobatic manoeuvres during charter flights Number: AO-2017-005-SI-04 Description: AO-2017-005-SI-04:The operator’s pilots routinely conducted near-aerobatic manoeuvres during passenger charter flights. However, procedures for these manoeuvres were not specified in the operator’s Operations Manual, and there were limited controls in place to manage the risk of these manoeuvres. Who it affects: The operator’s pilots and passengers. Issue owner: Wyndham Aviation Pty Ltd Operation affected: Aviation: Air transport	Date, status, type Date: 17 Oct 2019 Status: No longer relevant
Issue, description, who it affects Issue: AO-2017-005-SI-03Operator’s practices for securing baggage and other cargo Number: AO-2017-005-SI-03 Description: AO-2017-005-SI-03:Although the operator’s procedures required that baggage and cargo be secured during flight, this procedure was routinely not followed, and the aircraft were not equipped with cargo nets or other means for securing loads in the baggage compartment. Who it affects: The operator’s pilots and passengers. Issue owner: Wyndham Aviation Pty Ltd Operation affected: Aviation: Air transport	Date, status, type Date: 17 Oct 2019 Status: No longer relevant
Issue, description, who it affects Issue: AO-2017-005-SI-02Operator’s aircraft loading practices Number: AO-2017-005-SI-02 Description: AO-2017-005-SI-02:Although the operator’s procedures required that actual weights be used for passengers, baggage and other cargo, this procedure was routinely not followed, and pilots relied on estimated weights when calculating an aircraft’s weight and balance. Who it affects: The operator’s pilots and passengers. Issue owner: Wyndham Aviation Pty Ltd Operation affected: Aviation: Air transport	Date, status, type Date: 17 Oct 2019 Status: No longer relevant
Issue, description, who it affects Issue: AO-2017-005-SI-01Operator’s procedures and practices for airborne inspections of a landing area Number: AO-2017-005-SI-01 Description: AO-2017-005-SI-01:The operator normally conducted airborne inspections of the Middle Island aeroplane landing area at about 50–100 ft while flying at normal cruise speed towards an area of water, and its procedures did not ensure the effective management of the risk of an engine failure or power loss when at a ... Who it affects: The operator’s pilots and passengers. Issue owner: Wyndham Aviation Pty Ltd Operation affected: Aviation: Air transport	Date, status, type Date: 17 Oct 2019 Status: No longer relevant
Issue, description, who it affects Issue: RO-2018-019-SI-01Wiring error was not detected Number: RO-2018-019-SI-01 Description: RO-2018-019-SI-01:The wiring error was not detected by Metro Train Melbourne’s (MTM) verification program. Who it affects: Passenger rail transport operations Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 09 Oct 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-015-SI-01Process control Number: RO-2018-015-SI-01 Description: RO-2018-015-SI-01:V/Line did not have a documented detailed process for inhibiting and reinstating level crossing protection equipment. Who it affects: Rail: Passenger - regional Issue owner: V/Line Operation affected: Rail: Passenger - regional	Date, status, type Date: 08 Oct 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-069-SI-04Regulatory differentiation between community service flying and private operations Number: AO-2017-069-SI-04 Description: AO-2017-069-SI-04:CASA did not have a system to differentiate between community service flights and other private operations, which limited its ability to identify risks. This hindered the Civil Aviation Safety Authority's ability to manage risks associated with community service flights. Who it affects: All passengers on community service flights conducted by Angel Flight Australia Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: General aviation	Date, status, type Date: 13 Aug 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-069-SI-03Availability of safety information to Angel Flight Australia Number: AO-2017-069-SI-03 Description: AO-2017-069-SI-03:There were limited opportunities for Angel Flight to be made aware of any safety related information involving flights conducted on its behalf. Who it affects: All pilots conducting community service flights on behalf of Angel Flight Australia Issue owner: Angel Flight Australia Operation affected: Aviation: General aviation	Date, status, type Date: 13 Aug 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-069-SI-02Insufficient organisational risk controls implemented by Angel Flight Australia Number: AO-2017-069-SI-02 Description: AO-2017-069-SI-02:Angel Flight had insufficient controls in place, and provided inadequate guidance to pilots to address the additional operational risks associated with community service flights. Who it affects: All passengers on community service flights conducted by Angel Flight Australia Issue owner: Angel Flight Australia Operation affected: Aviation: General aviation	Date, status, type Date: 13 Aug 2019 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-069-SI-01 Angel Flight Australia consideration of commercial flights Number: AO-2017-069-SI-01 Description: AO-2017-069-SI-01 :Angel Flight did not consider the safety benefits of commercial passenger flights when suitable flights were available. Who it affects: All passengers on community service flights conducted by Angel Flight Australia Issue owner: Angel Flight Australia Operation affected: Aviation: General aviation	Date, status, type Date: 13 Aug 2019 Status: Safety action pending Type: Recommendation
Issue, description, who it affects Issue: RO-2017-009-SI-02Single source of information for Lookout Working prohibition Number: RO-2017-009-SI-02 Description: RO-2017-009-SI-02:Lookout Working (LOW) was implemented in an area deemed unsuitable for LOW on the Sydney Trains Worksite Protection Hazardous Locations Register (WPHLR). This is likely due to the WPHLR not being clearly stated as a reference with specific requirements that must be adhered to. Who it affects: All track managers Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 25 Jul 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-009-SI-01Use of warning lights Number: RO-2017-009-SI-01 Description: RO-2017-009-SI-01:Warning lights were utilised at Tempe to overcome sighting hazards and justify the use of Lookout Working (LOW). Warning lights rely on lookouts maintaining continuous observation and their use were not specifically referenced in the LOW Network Rules. Who it affects: All track managers Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 25 Jul 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-005-SI-02Management of rail stress Number: RO-2018-005-SI-02 Description: RO-2018-005-SI-02:A variety of techniques to indicate and record rail stress at specific locations are available, however, Aurizon had not used any of these techniques in some locations with elevated risk of rail stress, such as tangent track on steep grades. As a result, Aurizon could not readily determine the presence ... Who it affects: Train crew and passengers on board trains on Aurizon-owned track Issue owner: Aurizon Operation affected: Rail: Infrastructure	Date, status, type Date: 28 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-005-SI-01Use of hazard location register Number: RO-2018-005-SI-01 Description: RO-2018-005-SI-01:When planning track disturbing work, Aurizon’s normal practice was to use its Hazard Location Register as a record of past occurrences at a specific location. Aurizon did not use the Hazard Location Register as a resource to consider the situational characteristics of a location that may increase risk, such as ... Who it affects: Train crew and passengers on board trains on Aurizon-owned track Issue owner: Aurizon Operation affected: Rail: Infrastructure	Date, status, type Date: 28 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-009-SI-04Hydrographic use of point features Number: MO-2017-009-SI-04 Description: MO-2017-009-SI-04:The hydrographic use of point feature objects to represent physical features of relatively significant spatial extent on an Electronic Navigational Chart can increase the risk of the hazard posed by such features being misinterpreted by mariners and potentially reduce the effectiveness of the ECDIS safety checking functions. Who it affects: Vessels using Australian Electronic Navigational Charts Issue owner: Australian Hydrographic Office Operation affected: Marine: Shore-based operations	Date, status, type Date: 27 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-009-SI-03ECDIS software Number: MO-2017-009-SI-03 Description: MO-2017-009-SI-03:ECDIS on board most Australian Border Force cutters, including ABFC Roebuck Bay, operated with a non-type-approved naval software version that was not updated to the latest applicable standards of the International Hydrographic Organization. The ECDIS therefore did not comply with the minimum requirements of an ECDIS being used to meet ... Who it affects: Operators of Australian Border Force cutters Issue owner: Australian Border Force Operation affected: Marine: Shipboard operations	Date, status, type Date: 27 Jun 2019 Status: Adequately addressed Type: Proactive Action