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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2019-073-SI-05 Procedure for a rapid disembarkation Number: AO-2019-073-SI-05 Description: AO-2019-073-SI-05 :Qantas did not have a procedure for a rapid disembarkation, or other similar procedure that would effectively enable rapid deplaning at a slower and more controlled pace than an emergency evacuation. Therefore, the only option for rapid deplaning was an emergency evacuation utilising slides, which unnecessarily increased the risk of ... Issue owner: Qantas Airways Limited Operation affected: Aviation: Air transport	Date, status, type Date: 21 Jun 2022 Status: Open – Safety action pending Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2019-073-SI-02 Cabin crew training Number: AO-2019-073-SI-02 Description: AO-2019-073-SI-02 :Qantas's cabin crew recurrent training did not include any situation whereby a disarmed door would have to be rearmed in an emergency. This increased the likelihood that a door would be opened without the escape slide deployed, reducing the number of available exits. Issue owner: Qantas Airways Limited Operation affected: Aviation: Air transport	Date, status, type Date: 21 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2019-073-SI-01 Evacuation commands Number: AO-2019-073-SI-01 Description: AO-2019-073-SI-01 :Qantas's cabin crew primary evacuation commands did not include phrases such as 'leave everything behind' and 'jump and slide'; instead, these phrases were optional. Consequently, passengers would generally not receive specific guidance until they reached an exit, which would likely slow down the evacuation. Issue owner: Qantas Airways Limited Operation affected: Aviation: Air transport	Date, status, type Date: 21 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2019-073-SI-03 Passenger safety information Number: AO-2019-073-SI-03 Description: AO-2019-073-SI-03 :Qantas’s method of briefing passengers provided limited and inconsistent information about how to use the escape slides safely and what to do with cabin baggage in an emergency. Issue owner: Qantas Airways Limited Operation affected: Aviation: Air transport	Date, status, type Date: 21 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2018-022-SI-01Risk controls associated with pilots identifying fatigue risks associated with insufficient sleep and extended wakefulness Number: AO-2018-022-SI-01 Description: AO-2018-022-SI-01:The sleep log tool used by the operator contained a coding error and it also pre-loaded sleep periods of future nights by default. This combination of factors reduced the likelihood pilots would identify fatigue risks associated with insufficient sleep and extended wakefulness. Issue owner: Heli-Aust Whitsundays Pty Limited Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-022-SI-02Use of sleep reporting spreadsheet and potential for modification of data input to meet operator’s minimum requirements Number: AO-2018-022-SI-02 Description: AO-2018-022-SI-02:The operator's fatigue risk management system relied extensively on a sleep reporting spreadsheet (sleep log) that was based on the prior sleep wake model, and the spreadsheet had a transparent rule set that made the recorded data easy to modify to achieve results that met the operator’s minimum sleep and ... Issue owner: Heli-Aust Whitsundays Pty Limited Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-022-SI-04Operator’s circuit and approach procedures for marine pilot transfer operations and criteria for achieving a stabilised approach Number: AO-2018-022-SI-04 Description: AO-2018-022-SI-04:The operator’s circuit and approach procedures for marine pilot transfer operations did not minimise pilot workload or provide the recommended stabilised approach criteria with mandatory go-around policy. These procedures could allow a combination of conditions that increased the risk of a sustained abnormal flight path and collision with terrain/water. Issue owner: Heli-Aust Whitsundays Pty Limited Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-022-SI-005Operator’s training and assessing procedures for marine pilot transfer operations in degraded visual cueing environments Number: AO-2018-022-SI-005 Description: AO-2018-022-SI-005:The operator's training and assessing procedures for marine pilot transfer operations did not provide assurance that pilot under supervision experience, helicopter instrumentation, and instructor capability were suitable for line training at night in a degraded visual cueing environment. Issue owner: Heli-Aust Whitsundays Pty Limited Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-022-SI-03Configuration of instrument panel for instructor or training/check pilot in degraded visual cueing environments Number: AO-2018-022-SI-03 Description: AO-2018-022-SI-03:The instrument panels fitted to VH-ZGA and the operator's other EC135 helicopter at Port Hedland were equipped for single-pilot operation under the instrument flight rules. When used for flight training or checking in a degraded visual cueing environment, this configuration has a detrimental effect on the ability of an instructor ... Issue owner: Heli-Aust Whitsundays Pty Limited Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2019-063-SI-03Organisational change Number: AO-2019-063-SI-03 Description: AO-2019-063-SI-03:Changes in the operator's key safety post holder positions, safety reporting systems and internal processes reduced effective safety assurance. Issue owner: Alliance Airlines Pty Limited Operation affected: Aviation: Air transport	Date, status, type Date: 07 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2019-063-SI-02 Flight crew training Number: AO-2019-063-SI-02 Description: AO-2019-063-SI-02 :The operator’s training for the Fokker F28-Mk0100 did not prepare pilots for alpha mode activation during critical phases of flight. Issue owner: Alliance Airlines Pty Limited Operation affected: Aviation: Air transport	Date, status, type Date: 07 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2019-063-SI-01Safety management reporting system Number: AO-2019-063-SI-01 Description: AO-2019-063-SI-01:The operator’s safety management reporting system did not enable the effective prioritisation of submitted safety reports. Issue owner: Alliance Airlines Pty Limited Operation affected: Aviation: Air transport	Date, status, type Date: 07 Jun 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2021-023-SI-01Inadequate traffic alert and collision avoidance training Number: AO-2021-023-SI-01 Description: AO-2021-023-SI-01:The helicopter operator's traffic alert and collision avoidance system knowledge was inadequate with respect to resolution advisory alert terrain considerations and the required intensity of response manoeuvring. Issue owner: Babcock Mission Critical Services Australia Operation affected: Aviation: General aviation	Date, status, type Date: 27 May 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2020-038-SI-01External aircraft white lighting Number: AO-2020-038-SI-01 Description: AO-2020-038-SI-01:The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height., This delayed the identification and recovery from the unsafe aircraft state resulting in the pilot not identifying the developing rate of descent during the incident, delaying ... Issue owner: Helicorp Pty Ltd Operation affected: Aviation: Air transport	Date, status, type Date: 08 Apr 2022 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2020-012-SI-01ERSA procedure Number: AO-2020-012-SI-01 Description: AO-2020-012-SI-01:The En-Route Supplement Australia included a requirement to add 1,000 ft to the prescribed practice instrument approach ‘altitude’ at Mangalore Airport. The procedure did not detail whether this height was to be applied to the minimum descent altitude or to all approach altitudes, resulting in varied application and an increased ... Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: General aviation	Date, status, type Date: 31 Mar 2022 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: RO-2019-009-SI-004Management of late-notice roster changes Number: RO-2019-009-SI-004 Description: RO-2019-009-SI-004:Queensland Rail’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes. Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 29 Mar 2022 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2019-009-SI-001Placement of signal aspect indicators at station platforms Number: RO-2019-009-SI-001 Description: RO-2019-009-SI-001:Queensland Rail's process for the installation of signal aspect indicators (SAIs) did not provide sufficient detail to ensure consistent and conspicuous placement of SAIs at station platforms. This problem, combined with an SAI’s non-salient indication when the platform departure signal displayed a stop indication, increased the risk that an SAI ... Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 29 Mar 2022 Status: Closed – Partially addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-009-SI-003Risk management associated with changing allright signal procedures for the NGR Number: RO-2019-009-SI-003 Description: RO-2019-009-SI-003:Limitations in Queensland Rail’s application of risk management and change management processes relevant to the introduction of the new generation rollingstock (NGR) increased the risk of a start against signal SPAD (signals passed at danger). Specifically, multiple processes did not effectively consider the risk of station staff at suburban platforms ... Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 29 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO 2020 062 SI 01Ballina airport safety review Number: AO 2020 062 SI 01 Description: AO 2020 062 SI 01:The Civil Aviation Safety Authority review of the airspace surrounding Ballina Byron Gateway Airport did not include data for aircraft transiting the airspace without using the airport. Therefore, the risk associated with occurrences such as this one were not specifically considered when assessing the appropriate airspace classification. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Airspace management	Date, status, type Date: 25 Mar 2022 Status: Open – Safety action pending Type: Proactive action   Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-05 Fatigue management of train drivers Number: RO-2018-018-SI-05 Description: RO-2018-018-SI-05 :BHP's fatigue management processes required its train drivers to be rostered on 7 12-hour shifts, followed by a 24-hour break and then 7 12-hour shifts, with the roster pattern commencing at a wide variety of times of day. Such roster patterns were conducive to result in cumulative sleep restriction and ... Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Open – Safety action pending Type: Proactive action