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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2020-002-SI-02 Regulator guidance Number: AO-2020-002-SI-02 Description: AO-2020-002-SI-02 :Civil Aviation Safety Authority (CASA) advisory publications did not include information regarding the potential for reduction in braking performance resulting from active rainfall. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Air transport	Date, status, type Date: 01 Sep 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2020-002-SI-01 Operator guidance Number: AO-2020-002-SI-01 Description: AO-2020-002-SI-01 :The operator's documentation required crew to consider contamination of runways at the departure and destination airports. However, the provided definition and guidance did not include the means to identify water contamination from active rainfall. Issue owner: Network Aviation Operation affected: Aviation: Air transport	Date, status, type Date: 01 Sep 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2020-010-SI-02 Cabin exit design criteria (Issue owner: United States Federal Aviation Administration) Number: AO-2020-010-SI-02 Description: AO-2020-010-SI-02 :Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities. Issue owner: United States Federal Aviation Administration Operation affected: Aviation: Air transport	Date, status, type Date: 08 Jul 2021 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2020-010-SI-01 Cessna 206 emergency procedures Number: AO-2020-010-SI-01 Description: AO-2020-010-SI-01 :The Cessna 206 procedure for ditching and forced landing states that the flaps are to be extended to 40°. While that permits the aircraft to land at a slower speed, it also significantly restricts emergency egress via the cargo door. However, there is no warning about that aspect in the ... Issue owner: Textron Aviation Operation affected: Aviation: Air transport	Date, status, type Date: 08 Jul 2021 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2020-010-SI-02 Cabin exit design criteria (Issue owner: Civil Aviation Safety Authority) Number: AO-2020-010-SI-02 Description: AO-2020-010-SI-02 :Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Air transport	Date, status, type Date: 08 Jul 2021 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2020-036-SI-01 Maintenance manual supplement Number: AO-2020-036-SI-01 Description: AO-2020-036-SI-01 :The inspection procedures in the West Star Aviation maintenance manual supplement for extended life program Cessna 441 aircraft were inadequate to detect the progressive disbonding of the emergency exit door. Issue owner: West Star Aviation Operation affected: Aviation: Maintenance	Date, status, type Date: 30 Jun 2021 Status: Closed – Adequately addressed Type: Proactive action   Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2018-026-SI-01Operator consolidation processes for flight crew Number: AO-2018-026-SI-01 Description: AO-2018-026-SI-01:Although the operator complied with the regulatory requirements for training and experience of pilots, it had limited processes in place to ensure pilots with minimal time and experience on a new and technically different helicopter type had the opportunity to effectively consolidate their skills on the type required for conducting ... Issue owner: Whitsunday Air Services Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2021 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2018-026-SI-07Pilots leaving the controls of the helicopter Number: AO-2018-026-SI-07 Description: AO-2018-026-SI-07:It was common practice for the operator’s pilots to leave the controls of their helicopter, while the rotors were turning and the friction locks applied, to escort passengers to and from the helicopter. Issue owner: Whitsunday Air Services Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2021 Status: Closed – Partially addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-026-SI-06Operator management of birdstrikes Number: AO-2018-026-SI-06 Description: AO-2018-026-SI-06:There was often a significant number of birds located on the pontoons at Hardy Reef used by the operator. However, the operator did not have a process to systematically manage the risk of birdstrike. For example: The operator had not conducted a formal risk assessment of the bird hazard at the ... Issue owner: Whitsunday Air Services Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2021 Status: Closed – Partially addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-026-SI-05Operator helicopter loading practices Number: AO-2018-026-SI-05 Description: AO-2018-026-SI-05:Although the operator had calibrated scales available for use at two of their check-in locations, they were not routinely used to ascertain actual passenger and/or baggage weights. Instead, the operator's personnel relied on passengers’ volunteered weights (without an additional allowance) and only weighed passengers when the volunteered weights were perceived ... Issue owner: Whitsunday Air Services Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-026-SI-04Passengers with reduced mobility Number: AO-2018-026-SI-04 Description: AO-2018-026-SI-04:The operator’s system used to identify passengers with reduced mobility and/or required additional safety briefing information relied on passengers self-reporting a problem. Issue owner: Whitsunday Air Services Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2021 Status: Closed – Partially addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2018-026-SI-03Design of the EC120B rear left emergency exit Number: AO-2018-026-SI-03 Description: AO-2018-026-SI-03:Due to multiple factors, the design of the rear left sliding door (emergency exit) on the EC120B helicopter was not simple and obvious to use unless the occupant was provided with specific instructions about how to operate the exit. In particular: the door required three actions to open (pull handle up, ... Issue owner: Airbus Helicopters Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2021 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2018-026-SI-02Requirements for verbally briefing passengers on emergency exits Number: AO-2018-026-SI-02 Description: AO-2018-026-SI-02: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 method for operating the emergency exits. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2021 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2018-019-SI-01Fuel quantity assessment methods Number: AO-2018-019-SI-01 Description: AO-2018-019-SI-01:Although the operator had specified multiple methods of cross-checking fuel quantity gauge indications for its C441 fleet, there were limitations in the design, definition and/or application of these methods. These included: The primary method used (indicated versus calculated fuel) was self-referencing in nature, and not able to detect gradual changes in ... Issue owner: Skippers Aviation Operation affected: Aviation: Air transport	Date, status, type Date: 27 May 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2020-006-SI-01 Unapproved practice during TWA Number: RO-2020-006-SI-01 Description: RO-2020-006-SI-01 :There was an unapproved practice occurring during Track Work Authority of asking the Outer Handsignaller to remove Railway Track Signals from the track as a train was closely approaching in order to let it run free, which placed the Outer Handsignaller at risk of being struck by the train. Issue owner: Sydney Trains Operation affected: Rail: Infrastructure	Date, status, type Date: 20 May 2021 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: MO-2018-011-SI-05 Regulatory oversight Number: MO-2018-011-SI-05 Description: MO-2018-011-SI-05 :Regulatory safety oversight of Iron Chieftain, which comprised flag State audits, surveys and inspections had not identified safety deficiencies with respect to the ship’s fire safety, risk management, emergency preparedness and emergency response. Issue owner: Australian Maritime Safety Authority Operation affected: Marine: Other	Date, status, type Date: 11 May 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: MO-2018-011-SI-04Fire and Rescue New South Wales marine firefighting capability Number: MO-2018-011-SI-04 Description: MO-2018-011-SI-04:The capability of Fire and Rescue New South Wales to effectively respond to a shipboard fire in Port Kembla, was limited by: a lack of specialised marine firefighting expertise outdated marine training for firefighters relative inexperience in shipboard firefighting associated with the rarity of major shipboard fires an absence of marine-specific firefighting resources and ... Issue owner: Fire and Rescue New South Wales Operation affected: Marine: Other	Date, status, type Date: 11 May 2021 Status: Open – Safety action pending Type: Proactive action   Safety recommendation
Issue, description, who it affects Issue: MO-2018-011-SI-03 Shipboard emergency contingency plans Number: MO-2018-011-SI-03 Description: MO-2018-011-SI-03 :Iron Chieftain's Emergency Contingency Plan did not include a response plan to fire in the high fire risk self-unloading system spaces. Consequently, there was no clear plan or practiced sequence of actions that could aid emergency preparedness. Issue owner: Canada Steamship Lines Australia Operation affected: Marine: Shipboard operations	Date, status, type Date: 11 May 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: MO-2018-011-SI-02 Inadequate standards and regulation Number: MO-2018-011-SI-02 Description: MO-2018-011-SI-02 :The cargo handling spaces of specialised self-unloading bulk carriers continue to present a very high fire risk due to the inadequacy of standards or regulations for self-unloading systems, including for conveyor belts, and dedicated fire detection/fixed fire-extinguishing systems. This has been a factor in at least three major fires over ... Issue owner: Australian Maritime Safety Authority, Lloyd’s Register, and International Association of Classification Societies Operation affected: Marine: Other	Date, status, type Date: 11 May 2021 Status: Open – Safety action pending Type: Safety recommendation   Proactive action   Proactive action
Issue, description, who it affects Issue: MO-2018-011-SI-01 Management of risk Number: MO-2018-011-SI-01 Description: MO-2018-011-SI-01 :Iron Chieftain's operators had formally identified the fire risk in the ship’s cargo self-unloading system spaces, particularly the C-Loop, as being unacceptably high 5 years before the fire due to the absence of fire detection or fixed fire extinguishing system. However, at the time of the fire, the prevention and ... Issue owner: Canada Steamship Lines Australia Operation affected: Marine: Shore-based operations	Date, status, type Date: 11 May 2021 Status: Closed – Adequately addressed Type: Proactive action