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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2015-107-SI-02NAV ADR DISAGREE procedure Number: AO-2015-107-SI-02 Description: AO-2015-107-SI-02:A NAV ADR DISAGREE alert can be triggered by either an airspeed discrepancy, or angle of attack discrepancy. The alert does not identify which, and the associated procedure may lead flight crews to incorrectly diagnosing the source of the alert when the airspeed is erroneous for a short period and ... Who it affects: Operators of Airbus A320 aircraft Issue owner: Airbus Operation affected: Aviation: Air transport	Date, status, type Date: 04 Apr 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2015-107-SI-01Priority of NAV ADR DISAGREE alert Number: AO-2015-107-SI-01 Description: AO-2015-107-SI-01:Although the NAV ADR DISAGREE had more immediate safety implications relating to unreliable airspeed, the ECAM alert priority logic placed this alert below the engine-related faults. As a result, the NAV ADR DISAGREE alert was not immediately visible to the flight crew due to the limited space available on the ... Who it affects: Operators of Airbus A320 aircraft Issue owner: Airbus Operation affected: Aviation: Air transport	Date, status, type Date: 04 Apr 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-044-SI-02Re-evaluating hold speeds for a change in altitude Number: AO-2017-044-SI-02 Description: AO-2017-044-SI-02:The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude. Who it affects: Qantas Airways Boeing 747 flight crew Issue owner: Qantas Airways Operation affected: Aviation: Air transport	Date, status, type Date: 27 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-044-SI-01Stall prevention and recovery at high altitudes Number: AO-2017-044-SI-01 Description: AO-2017-044-SI-01:The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle. Who it affects: Qantas Airways Boeing 747 flight crew Issue owner: Qantas Airways Operation affected: Aviation: Air transport	Date, status, type Date: 27 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-001-SI-03Maintenance response to recurring track defects in areas with a degraded formation Number: RO-2016-001-SI-03 Description: RO-2016-001-SI-03:A more stringent maintenance response than that for an isolated track geometry defect was not considered or implemented in accordance with ARTC’s COP. A more stringent maintenance response should have been implemented given the degraded formation and the track’s rapid deterioration between 12-14 January 2016, two days prior to the ... Who it affects: Rail Infrastructure Managers (RIMs) Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Infrastructure	Date, status, type Date: 25 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-001-SI-01Shear key installation Number: RO-2016-001-SI-01 Description: RO-2016-001-SI-01:The shear key was not constructed in accordance with the geotechnical engineer’s specification with respect to the following: a) It did not include a cross-drain. b) Its width was less than the specified width. Who it affects: Rail Infrastructure Managers (RIMs) Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Infrastructure	Date, status, type Date: 25 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-001-SI-02Surface drainage in areas with degraded formations Number: RO-2016-001-SI-02 Description: RO-2016-001-SI-02:The infrastructure manager did not ensure that there was adequate surface drainage. Vegetation blocking the drains and the lack of an adequate gradient as well as the location being at a sag point likely contributed to this.  Who it affects: Rail Infrastructure Managers (RIMs) Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Infrastructure	Date, status, type Date: 25 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-016-SI-01Track defect management Number: RO-2017-016-SI-01 Description: RO-2017-016-SI-01:ARTC allowed identified track twist defects to remain in track contrary to network track geometry requirements. Who it affects: Track Managers Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Freight	Date, status, type Date: 06 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-002-SI-01Train driver maintenance of competency assurance Number: RO-2018-002-SI-01 Description: RO-2018-002-SI-01:Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements. Who it affects: Queensland Rail Citytrain rail traffic drivers Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 27 Feb 2019 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-001-SI-01Inadequate on-board documentation Number: MO-2017-001-SI-01 Description: MO-2017-001-SI-01:Guidelines for the provision, care and use of shipboard equipment were not supported by suitable documentation. The only documentation was for mobile scaffolding equipment of different design and not for that in use on the ship. Who it affects: All owners and operators and crewmembers involved in working aloft Issue owner: Asia Maritime Pacific Operation affected: Marine: Shipboard operations	Date, status, type Date: 21 Feb 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2015-007-SI-04Audit response Number: MO-2015-007-SI-04 Description: MO-2015-007-SI-04:The regional harbour master and the pilotage service did not have processes in place to follow up audit findings, to ensure that they were appropriately monitored, actioned and closed out in a timely manner. Who it affects: All ships entering and departing Townsville under pilotage Issue owner: Maritime Safety Queensland Operation affected: Marine: Shipboard operations	Date, status, type Date: 19 Feb 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2015-007-SI-03Tug reduction process Number: MO-2015-007-SI-03 Description: MO-2015-007-SI-03:The Port Procedures manual for Townsville allowed shipping agents to request a tug reduction without the knowledge of the ship’s master. Who it affects: All ships entering and departing Townsville under pilotage Issue owner: Maritime Safety Queensland and Port of Townsville Limited Pilotage Services Operation affected: Marine: Shipboard operations	Date, status, type Date: 19 Feb 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2015-007-SI-02Contingency planning Number: MO-2015-007-SI-02 Description: MO-2015-007-SI-02:The Port of Townsville Limited Pilotage Services’ Pilotage Service Safety Management System did not have documented guidance on berthing manoeuvres nor any associated contingencies. Who it affects: All ships entering and departing Townsville under pilotage Issue owner: Port of Townsville Limited Pilotage Services Operation affected: Marine: Shipboard operations	Date, status, type Date: 19 Feb 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2015-007-SI-01Risk management Number: MO-2015-007-SI-01 Description: MO-2015-007-SI-01:The Port of Townsville Limited Pilotage Service risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks during pilotage. Who it affects: All ships entering and departing Townsville under pilotage Issue owner: Port of Townsville Limited Pilotage Services Operation affected: Marine: Shipboard operations	Date, status, type Date: 19 Feb 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AR-2017-011-SI-01 Wake turbulence occurrences at Sydney Airport Number: AR-2017-011-SI-01 Description: AR-2017-011-SI-01 :Given the parallel runway configuration, there was a disproportionate rate of reported wake turbulence occurrences for aircraft arriving at Sydney Airport compared to other major Australian airports in the years 2012 to 2016. Wake turbulence occurrences at Sydney Airport were found to be primarily associated with three factors: arrival densities of ... Who it affects: Aircraft arriving at Sydney Airport Issue owner: Airservices Australia Operation affected: Aviation: Air transport	Date, status, type Date: 15 Feb 2019 Status: Safety action pending Type: Recommendation
Issue, description, who it affects Issue: RO-2017-001-SI-01Loading of train Number: RO-2017-001-SI-01 Description: RO-2017-001-SI-01:The train was loaded by approximately 10 per cent more than that recorded on the consist, it is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train. Who it affects: All owners and operators of freight wagons Issue owner: Qube Logistics Operation affected: Rail: Freight	Date, status, type Date: 05 Dec 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2016-160-SI-01Policies and procedures for planning IFR and NVIS flights Number: AO-2016-160-SI-01 Description: AO-2016-160-SI-01:Although the operator’s operations manual stated that emergency medical service flights should be conducted under instrument flight rules (IFR) ‘where practical’, its procedures for night visual flight rules (NVFR) operations using night vision goggles did not clearly state when IFR rather than NVFR should be used.   Who it affects: Operating crew and other occupants on emergency medical service flights Issue owner: CHC Helicopter Australia Operation affected: Aviation: Air transport	Date, status, type Date: 06 Nov 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2018-016-SI-02 Balloon passenger briefing procedures Number: AO-2018-016-SI-02 Description: AO-2018-016-SI-02 :Although the operator had procedures for conducting a verbal safety briefing prior to flight and had safety briefing cards available, its risk controls did not provide assurance that all passengers would understand the required procedures for emergency landings. More specifically: safety briefing cards were not routinely made available to passengers prior ... Who it affects: Crew and passengers on the operator’s flights Issue owner: Go Wild Ballooning Pty Ltd Operation affected: Aviation: General aviation	Date, status, type Date: 30 Oct 2018 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2018-016-SI-01 Procedures for uploading balloon forecasts Number: AO-2018-016-SI-01 Description: AO-2018-016-SI-01 :The Bureau of Meteorology did not have a procedure to ensure that a recording of the local weather forecast for balloon operations in the Melbourne area was correctly uploaded and accessible to balloon pilots. Who it affects: All balloon operators and pilots in the Melbourne region Issue owner: Bureau of Meteorology Operation affected: Aviation: General aviation	Date, status, type Date: 30 Oct 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2015-023-SI-01 Rail condition Number: RO-2015-023-SI-01 Description: RO-2015-023-SI-01 :The general condition of the rail on the west track, in the vicinity of the rail fracture, contributed to relatively frequent failures in that area. Who it affects: Users of the affected rail track Issue owner: BHP Billiton Operation affected: Rail: Freight	Date, status, type Date: 12 Oct 2018 Status: Adequately addressed Type: Proactive Action