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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2015-089-SI-01 Cicaré S.A. CH-7T/B/BT service bulletin
Number: AO-2015-089-SI-01
Description: AO-2015-089-SI-01 :The Cicaré 7T/B/BT mandatory service bulletin (BSC007) for the general stabiliser support assembly provided limited guidance for disassembly of the manufactured component and did not stipulate a compliance period within which to perform the inspection nor provide consideration for repeat inspections. This potentially reduced the opportunity to detect the presence ...
Who it affects: All owners and operators of Cicaré CH7T/B/BT helicopters
Issue owner: Cicaré S.A.
Operation affected: Aviation: General aviation
Date, status, type
Date: 20 Dec 2019
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2018-004-SI-05Rostering of the driver inconsistent with rostering principles
Number: RO-2018-004-SI-05
Description: RO-2018-004-SI-05:The rostering of the driver in the days leading up to the incident was inconsistent with Sydney Trains' rostering principles.
Who it affects: Rail rostering managers
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 20 Dec 2019
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2018-004-SI-04Management of risk associated with intermediate train stop installation
Number: RO-2018-004-SI-04
Description: RO-2018-004-SI-04:Sydney Trains risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances where the presence of an intermediate train stop at Richmond may have reduced the risk of trains approaching the station at excessive speed.
Who it affects: Rail infrastructure managers
Issue owner: Sydney Trains
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 Dec 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2018-004-SI-03Management of risk associated with buffer stop deficiencies
Number: RO-2018-004-SI-03
Description: RO-2018-004-SI-03:Sydney Trains’ risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when there were deficiencies in the buffer stop design at Richmond and at other locations.
Who it affects: Rail infrastructure managers
Issue owner: Sydney Trains
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 Dec 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2018-004-SI-02Buffer stop effectiveness in collision
Number: RO-2018-004-SI-02
Description: RO-2018-004-SI-02:When A42 collided with buffer stop at Richmond station No. 2 platform the reinforced concrete end stop of the buffer stop withstood the impact of the collision and prevented the train from crossing into a pedestrian and main road precinct. The two hydro-pneumatic rams on the front of the buffer ...
Who it affects: Rail infrastructure managers
Issue owner: Sydney Trains
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 Dec 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2018-004-SI-01Crash energy management system did not perform as designed
Number: RO-2018-004-SI-01
Description: RO-2018-004-SI-01:The crash energy management system on the Waratah passenger train A42 reduced the impact force of the collision but not all components performed as designed. The performance of the crash energy management system was significantly limited by the buffer stop at Richmond being incompatible with the front of the Waratah ...
Who it affects: Rolling stock designers and rail infrastructure managers
Issue owner: Downer
Operation affected: Rail: Rolling stock
Date, status, type
Date: 20 Dec 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2017-098-SI-01Passenger oxygen mask instructions
Number: AO-2017-098-SI-01
Description: AO-2017-098-SI-01:The pre-flight safety briefing and safety information card did not include a clear instruction on how to activate the flow of oxygen from the passenger oxygen masks and that the bag may not inflate when oxygen is flowing. This resulted in some passengers not understanding whether or not there was ...
Who it affects: Airline passengers
Issue owner: AirAsia Indonesia
Operation affected: Aviation: Air transport
Date, status, type
Date: 26 Nov 2019
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: AO-2017-013-SI-01Air display approval and oversight
Number: AO-2017-013-SI-01
Description: AO-2017-013-SI-01:The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors: While the Air Display Manual provided guidance to organisers conducting an air display, it did not inherently provide the processes and tools needed for CASA to approve ...
Who it affects: Air displays: Organisers and participants in air displays
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Other
Date, status, type
Date: 19 Nov 2019
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2017-010-SI-02Usage of tugs
Number: MO-2017-010-SI-02
Description: MO-2017-010-SI-02:Tugs were to be available to escort the mini cape-size ships until they had entered the South Channel, where they were then stood down. However, the tug masters had not been trained in the specifics of escort towage nor in emergency response.
Who it affects: All owners, operators and crewmembers involved in pilotage
Issue owner: Ports North
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Nov 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2017-010-SI-01Mini cape-size risk assessment
Number: MO-2017-010-SI-01
Description: MO-2017-010-SI-01:In pre-trial simulations, the risks associated with engine failure during departure were only considered up to when a ship had entered the South Channel. Consequently, the tugs were not in attendance to assist if propulsion was lost.
Who it affects: All owners, operators and crewmembers involved in pilotage
Issue owner: Maritime Safety Queensland
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Nov 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2018-007-SI-01Advantage 70 engine modification
Number: AO-2018-007-SI-01
Description: AO-2018-007-SI-01:There were a total of 16 engine malfunction events globally over a 4-year period attributed to modification of the Advantage 70™ engine. The modification increased the engine outer duct gas path temperature, which led to distortion and liberation of the outer transition duct segments.
Who it affects: All operators of Airbus A330 aircraft fitted with Pratt & Whitney PW4170 engines or Advantage 70™ engine modification.
Issue owner: Pratt & Whitney
Operation affected: Aviation: Air transport
Date, status, type
Date: 06 Nov 2019
Status: Safety action pending
Type: Proactive Action
  Recommendation
  Recommendation
Issue, description, who it affects
Issue: MO-2018-001-SI-01 Knowledge and use of fall arrest safety equipment
Number: MO-2018-001-SI-01
Description: MO-2018-001-SI-01 :The fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform the equipment would not have worked correctly, resulting in serious or fatal injuries.
Who it affects: All workers on ship
Issue owner: Berge Bulk Maritime
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 30 Oct 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2018-025-SI-01CASA ALA guidance on runway overrun areas
Number: AO-2018-025-SI-01
Description: AO-2018-025-SI-01:The Civil Aviation Advisory Publication for Aeroplane Landing Areas (92-1(1)) did not have guidance for the inclusion of a safe runway overrun area.
Who it affects: All owners and users of ALAs
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 22 Oct 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2017-005-SI-08Regulatory surveillance – scoping of surveillance events
Number: AO-2017-005-SI-08
Description: AO-2017-005-SI-08:The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or ...
Who it affects: All operators.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2017-005-SI-07 Requirements for briefing the brace position in small aircraft
Number: AO-2017-005-SI-07
Description: AO-2017-005-SI-07 :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 brace position for an emergency landing or ditching, even for aircraft without upper torso restraints fitted to all passenger seats.
Who it affects: All aircraft owners, operators, pilots and passengers of small aeroplanes.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: Safety action pending
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2017-005-SI-06 Requirements for upper torso restraints in small aircraft
Number: AO-2017-005-SI-06
Description: AO-2017-005-SI-06 :Upper torso restraints (UTRs) were not required for all passenger seats for small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992, including for passenger transport operations. Although options for retrofitting UTRs are available for many models of small aircraft, many of these aircraft manufactured before the applicable ...
Who it affects: All aircraft owners, operators, pilots and passengers of small aircraft without upper torso restraints for all passenger seats.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2017-005-SI-05Operator’s processes for reviewing its operations
Number: AO-2017-005-SI-05
Description: AO-2017-005-SI-05:There were a significant number and variety of problems associated with the operator’s activities that increased safety risk, and the operator’s chief pilot held all the key positions within the operator’s organisation and conducted most of the operator’s flights. Overall, there were no effective mechanisms in place to regularly and ...
Who it affects: The operator’s pilots and passengers.
Issue owner: Wyndham Aviation Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: No longer relevant
Issue, description, who it affects
Issue: AO-2017-005-SI-04Operator’s conduct of near-aerobatic manoeuvres during charter flights
Number: AO-2017-005-SI-04
Description: AO-2017-005-SI-04:The operator’s pilots routinely conducted near-aerobatic manoeuvres during passenger charter flights. However, procedures for these manoeuvres were not specified in the operator’s Operations Manual, and there were limited controls in place to manage the risk of these manoeuvres.
Who it affects: The operator’s pilots and passengers.
Issue owner: Wyndham Aviation Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: No longer relevant
Issue, description, who it affects
Issue: AO-2017-005-SI-03Operator’s practices for securing baggage and other cargo
Number: AO-2017-005-SI-03
Description: AO-2017-005-SI-03:Although the operator’s procedures required that baggage and cargo be secured during flight, this procedure was routinely not followed, and the aircraft were not equipped with cargo nets or other means for securing loads in the baggage compartment.
Who it affects: The operator’s pilots and passengers.
Issue owner: Wyndham Aviation Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: No longer relevant
Issue, description, who it affects
Issue: AO-2017-005-SI-02Operator’s aircraft loading practices
Number: AO-2017-005-SI-02
Description: AO-2017-005-SI-02:Although the operator’s procedures required that actual weights be used for passengers, baggage and other cargo, this procedure was routinely not followed, and pilots relied on estimated weights when calculating an aircraft’s weight and balance.
Who it affects: The operator’s pilots and passengers.
Issue owner: Wyndham Aviation Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: No longer relevant
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