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Safety issues and actions
Issue, description, who it affects Date, status, type
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
Issue, description, who it affects
Issue: MO-2017-009-SI-02Vessel survey and certification
Number: MO-2017-009-SI-02
Description: MO-2017-009-SI-02:Most Australian Border Force cutters, including ABFC Roebuck Bay, were installed with ECDIS operating on non-type-approved naval software. Subsequently, DNV GL, acting on behalf of the Australian Maritime Safety Authority, incorrectly certified these vessels as using type-approved ECDIS to meet the chart carriage requirements of the regulations. This removed an ...
Who it affects: Australian flagged vessels
Issue owner: Australian Maritime Safety Authority
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-01ECDIS familiarisation
Number: MO-2017-009-SI-01
Description: MO-2017-009-SI-01:Although the online VisionMaster FT ECDIS type-specific familiarisation training included the relevant content, the training as undertaken by Australian Border Force deck officers was not effective in preparing ABFC Roebuck Bay's officers for the operational use of the ECDIS.
Who it affects: Australian Border Force deck officers
Issue owner: Australian Border Force
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jun 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2017-007-SI-01 QR’s track monitoring and inspection processes
Number: RO-2017-007-SI-01
Description: RO-2017-007-SI-01 :Queensland Rail’s track monitoring and inspection processes were not effective in identifying significant deterioration in the condition of level crossing ID 2309 and its approach roads to ensure the safe operating limits of the level crossing throughout its lifecycle.
Who it affects: Rail Infrastructure Managers, Rail Operators and Road Authorities/Managers
Issue owner: Queensland Rail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 25 Jun 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2017-013-SI-02Axle fatigue susceptibility
Number: RO-2017-013-SI-02
Description: RO-2017-013-SI-02:The GATX 840P1 axle was susceptible to fatigue cracking due to relatively minor damage that was not reliably detected prior to failure.
Who it affects: All users of 840P1 axles
Issue owner: Incitec Pivot Limited
Operation affected: Rail: Rolling stock
Date, status, type
Date: 12 Jun 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2017-013-SI-01Magnetic particle inspection
Number: RO-2017-013-SI-01
Description: RO-2017-013-SI-01:Anomalies in the magnetic particle inspection procedures likely led to the crack not being detected.
Who it affects: All workers conducting magnetic particle inspection
Issue owner: Aurizon
Operation affected: Rail: Rolling stock
Date, status, type
Date: 12 Jun 2019
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2014-032-SI-08Undetected horizontal stabiliser damage in world fleet
Number: AO-2014-032-SI-08
Description: AO-2014-032-SI-08:As a legacy of there being no inspection specific to an in-flight pitch disconnect, there is potential for other ATR aircraft to have sustained an in-flight pitch disconnect in the past and be operating with undetected horizontal stabiliser damage.
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-032-SI-07Maintenance requirements following an in-flight pitch disconnect
Number: AO-2014-032-SI-07
Description: AO-2014-032-SI-07:The aircraft manufacturer, ATR, did not provide a maintenance inspection to specifically assess the effect of an in-flight pitch disconnect on the structural integrity of the horizontal stabilisers. As a result, if an in-flight pitch disconnect occurred, the aircraft may not be inspected at a level commensurate with the criticality ...
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-032-SI-06No consideration of dual control inputs on aircraft response in the design standard
Number: AO-2014-032-SI-06
Description: AO-2014-032-SI-06:Although the design standard for the aircraft (JAR-25) required the control system to be of sufficient strength to withstand dual control inputs, it did not require consideration of the effect that dual control inputs may have on control of the aircraft. Similarly, the current design standard (CS-25) does not address ...
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: European Aviation Safety Agency (EASA)
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2014-032-SI-05No consideration of transient control loads in the design standard
Number: AO-2014-032-SI-05
Description: AO-2014-032-SI-05:The design standard for large transport aircraft, Joint Aviation Requirements - Part 25 (JAR-25), did not require that the demonstrated potential for flexibility in the control system to develop transient dynamic loads, be considered during certification. Similarly, the current certification standard for Large Aeroplanes (CS-25) does not address this issue.
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: European Aviation Safety Agency (EASA)
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-032-SI-04Effect of dual control inputs on elevator response
Number: AO-2014-032-SI-04
Description: AO-2014-032-SI-04:Flexibility in the ATR 72’s pitch control system between the control columns results in a change in the aircraft’s longitudinal handling qualities and control dynamics when dual control inputs are made. This could result in an aircraft-pilot coupling event where flight crew may find it difficult to control the aircraft.
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Safety action pending
Type: Recommendation
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