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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2016-003-SI-01 Air traffic facilities at Ballina/Byron Gateway Airport
Number: AO-2016-003-SI-01
Description: AO-2016-003-SI-01 :Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence ...
Who it affects: All aircraft operations that utilise Ballina/Byron Gateway Airport
Issue owner: Operator-Ballina/Byron Gateway Airport
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-04 Correcting rail creep for fixed points
Number: RO-2015-022-SI-04
Description: RO-2015-022-SI-04 :Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-03 Timeframe for addressing identified rail creep
Number: RO-2015-022-SI-03
Description: RO-2015-022-SI-03 :The procedures for measuring, assessing, and remediating rail creep in spring did not ensure creep defects were addressed in a timely manner and prior to the onset of hot weather. A creep defect identified by the spring measurements was not corrected before the derailment.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-02 Other track inspections
Number: RO-2015-022-SI-02
Description: RO-2015-022-SI-02 :There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-01 Rail creep
Number: RO-2015-022-SI-01
Description: RO-2015-022-SI-01 :Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2016-001-SI-03Mooring at Station Pier
Number: MO-2016-001-SI-03
Description: MO-2016-001-SI-03:While TT-Line Company’s standard mooring line pattern for ships at Station Pier had been successfully used for many years, the breakaway indicated the risk could have been further reduced to better prepare for such unusual circumstances.
Who it affects: All ship masters and deck officers
Issue owner: TT-Line Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 May 2017
Status: Partially addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2016-001-SI-02Melbourne vessel traffic service procedures
Number: MO-2016-001-SI-02
Description: MO-2016-001-SI-02:The Port of Melbourne vessel traffic service (VTS) procedures for adverse weather were not comprehensive and, hence, its response on 13 January was only partially effective. One important consequence was that VTS’s advance warning of storm force winds did not reach all relevant parties, including Spirit of Tasmania II’s master.
Who it affects: Port of Melbourne vessel traffic service and all users of the port
Issue owner: Victorian Ports Corporation (Melbourne)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 11 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2016-001-SI-01TT-Line Company procedures
Number: MO-2016-001-SI-01
Description: MO-2016-001-SI-01:The adverse weather procedures for TT-Line Company ships when alongside did not take into account all the necessary factors to provide effective defences against significant, short-term weather events such as thunderstorms and squalls.
Who it affects: All ship masters and deck officers
Issue owner: TT-Line Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-032-SI-02Consideration of transient elevator deflections from a pitch disconnect
Number: AO-2014-032-SI-02
Description: AO-2014-032-SI-02:The aircraft manufacturer did not account for the transient elevator deflections that occur as a result of the system flexibility and control column input during a pitch disconnect event at all speeds within the flight envelope. As such, there is no assurance that the aircraft has sufficient strength to withstand ...
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 05 May 2017
Status: Safety action pending
Type: Recommendation
  Recommendation
  Recommendation
  Proactive Action
Issue, description, who it affects
Issue: AO-2017-032-SI-01GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Number: AO-2017-032-SI-01
Description: AO-2017-032-SI-01:The ATSB advises that those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3 should note the facts presented in this preliminary report with a view to addressing any risks ...
Who it affects: Those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Issue owner: Operators and maintainers of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Operation affected: Aviation: Air transport
Date, status, type
Date: 13 Apr 2017
Status: Safety action pending
Type: Safety Advisory Notice
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-120-SI-01Emergency oxygen mask and smoke goggles training
Number: AO-2013-120-SI-01
Description: AO-2013-120-SI-01:At the time of the occurrence, the approved QantasLink training did not provide first officers with sufficient familiarity on the use of the oxygen mask and smoke goggles. This likely contributed to the crew's communication difficulties, including with air traffic control.
Who it affects: All QantasLink DHC-8-315 pilots
Issue owner: QantasLink
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Apr 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-005-SI-01Absence of air traffic control procedures and tools for runway changes at Melbourne Airport
Number: AO-2016-005-SI-01
Description: AO-2016-005-SI-01:Airservices Australia did not provide procedures with associated local instructions to Melbourne air traffic controllers regarding how to coordinate runway changes at Melbourne Airport. Furthermore, an absence of system tools increased the risk of the controllers forgetting to coordinate those changes with the Essendon Aerodrome Controller.
Who it affects: Air traffic controllers at Melbourne and Essendon Airports
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 09 Mar 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-009-SI-02 Network rule governing Distant signals
Number: RO-2015-009-SI-02
Description: RO-2015-009-SI-02 :The rule describing the required driver response to a Distant signal at Caution in a two-position signalling system did not fully reflect the signalling system design principles. 
Who it affects: Drivers operating on rail networks using this rule
Issue owner: V/Line
Operation affected: Rail: Operations control
Date, status, type
Date: 12 Dec 2016
Status: Not addressed
Type: Recommendation
  Proactive Action
Issue, description, who it affects
Issue: RO-2015-009-SI-01 Driver training
Number: RO-2015-009-SI-01
Description: RO-2015-009-SI-01 :The training and assessment of the driver did not ensure that he had an adequate understanding of the two-position signalling through Marshall. 
Who it affects: Drivers operating on the V/Line network
Issue owner: V/Line
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 12 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-028-SI-02 Operational rules and procedures
Number: RO-2015-028-SI-02
Description: RO-2015-028-SI-02 :The Queensland Rail network rules, procedures and safety manual provided insufficient guidance to identify the magnitude of the potential hazard from a weather event, or define the response when encountering water that had previously overtopped the track and receded or was pooled against the track formation or ballast.
Who it affects: All rail safety workers conducting work on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-028-SI-01 Hazard identification and assessment by rail traffic crew
Number: RO-2015-028-SI-01
Description: RO-2015-028-SI-01 :The Queensland Rail General Operational Safety Manual (MD-10-107) contained insufficient guidance for rail traffic crews to ensure the timely identification and management of a potential hazard (resulting from a weather event) that might affect the safe progress of the train.
Who it affects: All rail transport operators working rolling stock on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-096 -SI-01Compromised separation recovery training
Number: AO-2014-096 -SI-01
Description: AO-2014-096 -SI-01:Compromised separation recovery training deficiencies existed within the Department of Defence at the time of the occurrence, increasing the risk of inappropriate management of aircraft in close proximity. Note: This safety issue was identified as part of ATSB investigation AO-2012-131 as safety issue AO-2012-131-SI-05 and resulted in the ATSB issuing safety recommendation AO‑2012‑131‑SR‑042 on 2 October 2014 (after the ...
Who it affects: All Department of Defence air traffic controllers
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 05 Dec 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2014-164-SI-01Potential adverse effects of a tip-up canopy opening in-flight
Number: AO-2014-164-SI-01
Description: AO-2014-164-SI-01:In‑flight opening of the tip-up canopy in a number of Van’s Aircraft Inc. models has resulted in varying consequences, including a significant pitch down tendency, increasing the risk of a loss of control. 
Who it affects: Owners of Van’s aircraft fitted with a tip-up canopy
Issue owner: Van’s Aircraft Inc.
Operation affected: Aviation: General aviation
Date, status, type
Date: 25 Nov 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-005-SI-03Open stern offshore support vessels
Number: MO-2015-005-SI-03
Description: MO-2015-005-SI-03:Skandi Pacific’s managers had not adequately assessed the risks associated with working on the aft deck of vessels with open sterns, including consideration of engineering controls to minimise water being shipped on the aft deck.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Partially addressed
Type: Proactive Action
  Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2015-005-SI-02Cargo securing procedures
Number: MO-2015-005-SI-02
Description: MO-2015-005-SI-02:Skandi Pacific’s safety management system (SMS) procedures for cargo securing were inadequate. There was no guidance for methods of securing cargo in adverse weather conditions.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Adequately addressed
Type: Proactive Action
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