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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2020-041-S1-01Maintenance Publications Number: AO-2020-041-S1-01 Description: AO-2020-041-S1-01:While the manufacturer's instructions for the zonal inspections detailed that installation blankets could be removed 'as necessary', they did not reference the insulation blanket installation procedure. This resulted in insulation blankets not being secured to the structure. Issue owner: Fokker Services Operation affected: Aviation: Maintenance	Date, status, type Date: 22 Jan 2021 Status: Open – Safety action pending Type: Proactive action   Proactive action   Proactive action   Proactive action
Issue, description, who it affects Issue: RO-2018-009-SI-01 Inspection processes Number: RO-2018-009-SI-01 Description: RO-2018-009-SI-01 :Pacific National’s inspection processes did not identify key structural points for inspection on RRYY class wagons, including the susceptibility to cracking in the junction between container loading outriggers, pull rod boxed opening, and the bottom centre sill sections. This reduced the likelihood of cracks being detected. Issue owner: Pacific National Operation affected: Rail: Freight	Date, status, type Date: 23 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2016-155-SI-01 Compressor turbine blade failure Number: AO-2016-155-SI-01 Description: AO-2016-155-SI-01 :Pratt & Whitney Canada (PWC) PT6A-114A engines fitted with compressor turbine vane rings that have been repaired in accordance with the United States Federal Aviation Administration‑approved scheme STI 72-50-254 have a significantly increased likelihood of CMSX-6 compressor turbine blade fracture and subsequent failure of the engine compared to those engines ... Issue owner: United States Federal Aviation Administration Operation affected: Aviation: Air transport	Date, status, type Date: 18 Dec 2020 Status: Open – Safety action pending Type: Proactive action   Proactive action   Proactive action   Proactive action   Proactive action   Proactive action
Issue, description, who it affects Issue: RO-2019-003-SI-01 Management of track lateral stability Number: RO-2019-003-SI-01 Description: RO-2019-003-SI-01 :The ARTC systems for managing track lateral stability did not lead to the location being managed as a location potentially vulnerable to instability. Issue owner: Australian rail Track Corporation Operation affected: Rail: Freight	Date, status, type Date: 16 Dec 2020 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2019-055-SI-02 Runway verification cues Number: AO-2019-055-SI-02 Description: AO-2019-055-SI-02 :Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway. Issue owner: Virgin Australia Airlines Operation affected: Aviation: Air transport	Date, status, type Date: 11 Dec 2020 Status: Open – Safety action pending
Issue, description, who it affects Issue: AO-2019-055-SI-01 Timing of 'before take-off' procedure Number: AO-2019-055-SI-01 Description: AO-2019-055-SI-01 :Virgin Australia Airlines did not require ATR flight crews to complete the Before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying ... Issue owner: Virgin Australia Airlines Operation affected: Aviation: Air transport	Date, status, type Date: 11 Dec 2020 Status: No longer relevant
Issue, description, who it affects Issue: RO-2018-008-SI-04Radial unitising straps not required in the Freight Loading Manual Number: RO-2018-008-SI-04 Description: RO-2018-008-SI-04:Pacific National's Freight Loading Manual did not require the use of radial unitising straps to prevent telescoping on jumbo coils where the thickness of the steel was greater than 2 mm. Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-008-SI-03Load restraint system Number: RO-2018-008-SI-03 Description: RO-2018-008-SI-03:Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose. Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Open – Safety action pending Type: Proactive action   Safety recommendation
Issue, description, who it affects Issue: RO-2018-008-SI-02Radial unitising straps contacting the cradle Number: RO-2018-008-SI-02 Description: RO-2018-008-SI-02:Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of ... Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: RO-2018-008-SI-01Rubber load mats not required in the Freight Loading Manual Number: RO-2018-008-SI-01 Description: RO-2018-008-SI-01:Pacific National's Freight Loading Manual, specific to the loading and unitising of jumbo coils, did not require the use of rubber load mat on cradles. Consequently, there was no requirement to consider the condition of load mat during inspection and maintenance. This allowed the continued use of cradles without load ... Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2020-005-SI-01 Alstom's validation and fault monitoring processes Number: RO-2020-005-SI-01 Description: RO-2020-005-SI-01 :Neither Alstom’s validation processes nor fault monitoring processes were sufficient to detect the overcharging of batteries prior to the event. Issue owner: Alstom Australia Limited Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 03 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-013-SI-02 Maintenance records Number: RO-2019-013-SI-02 Description: RO-2019-013-SI-02 :Inspection records for the December 2010 wheelset maintenance activity and wheel change on wheelset number 7E5S 831444 were not available. It is a requirement specified in Pacific National's Wagon Maintenance Manual that records be retained for a period of 12 years. Who it affects: All owners and maintainers of rolling stock Issue owner: Pacific National Operation affected: Rail: Rolling stock	Date, status, type Date: 24 Nov 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-013-SI-01 Axle testing Number: RO-2019-013-SI-01 Description: RO-2019-013-SI-01 :Axle testing on wheelset number 7E5S 831444 was not carried out during the two most recent wheelset maintenance events in January 2016 and November 2016. It is likely the axle crack existed at the time of these maintenance activities. Who it affects: All owners and maintainers of rolling stock Issue owner: Pacific National Operation affected: Rail: Rolling stock	Date, status, type Date: 24 Nov 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-014-SI-02Elements of the safety and environment management system not error tolerant Number: RO-2019-014-SI-02 Description: RO-2019-014-SI-02:Elements of the safety and environment management system are reliant on procedures being followed to manage safety risks. There is little scope for the system to recover when there has been a human error or other procedural error. Issue owner: PerisherBlue Pty Ltd Operation affected: Rail: Operations control	Date, status, type Date: 17 Nov 2020 Status: Closed – Partially addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-014-SI-03Positive isolation Number: RO-2019-014-SI-03 Description: RO-2019-014-SI-03:The system of placing protection flags on both ends of a train set does not provide a positive isolation of energy to ensure a train cannot be moved while it is being worked on. Issue owner: PerisherBlue Pty Ltd Operation affected: Rail: Operations control	Date, status, type Date: 17 Nov 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-014-SI-01Managing track access Number: RO-2019-014-SI-01 Description: RO-2019-014-SI-01:The Skitube system for managing access to track did not detect the conflict of the rail maintenance worker under the train at the same time the train was being shunted. Issue owner: PerisherBlue Pty Ltd Operation affected: Rail: Operations control	Date, status, type Date: 17 Nov 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-006-SI-02Pilot’s operating handbook Number: AO-2018-006-SI-02 Description: AO-2018-006-SI-02:The Robinson R44 pilot’s operating handbook low rotor RPM recovery procedure did not include reference to the minimum power airspeed for the helicopter as a consideration, which may assist a pilot to recover from a low rotor RPM condition. Issue owner: Robinson Helicopter Company Operation affected: Aviation: Air transport	Date, status, type Date: 07 Oct 2020 Status: Open – Safety action pending Type: Proactive action   Safety recommendation
Issue, description, who it affects Issue: AO-2018-006-SI-01Passenger scales Number: AO-2018-006-SI-01 Description: AO-2018-006-SI-01:Professional Helicopter Services did not have a calibration schedule for their passenger scales, which were under-reading. This increased the risk of their helicopters not achieving their expected take-off performance. Issue owner: Professional Helicopter Services Operation affected: Aviation: Air transport	Date, status, type Date: 07 Oct 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-032-SI-03Inhibition of safety alerts for combined air traffic control roles Number: AO-2018-032-SI-03 Description: AO-2018-032-SI-03:Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combined roles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation ... Who it affects: Tower controllers at Perth Airport Issue owner: Airservices Australia Operation affected: Aviation: Airspace management	Date, status, type Date: 01 Oct 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-032-SI-02Location and design of taxiway J2 at Perth Airport Number: AO-2018-032-SI-02 Description: AO-2018-032-SI-02:The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient ... Who it affects: All flight crew and operators of jet aircraft using runway 03 at Perth Airport Issue owner: Perth Airport Pty Ltd Operation affected: Aviation: Air transport	Date, status, type Date: 01 Oct 2020 Status: Closed – Adequately addressed Type: Proactive action   Proactive action