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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2019-015-SI-01 Aeropower post-training supervision Number: AO-2019-015-SI-01 Description: AO-2019-015-SI-01 :There were no requirements in Aeropower procedures to provide any post-training supervision for powerline operations. What supervision was provided was ineffective in identifying that a modified stringing method was being used by the pilot. Issue owner: Aeropower Pty. Ltd. Operation affected: Aviation: General aviation	Date, status, type Date: 09 Mar 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2019-025-SI-05Crew risk awareness Number: AO-2019-025-SI-05 Description: AO-2019-025-SI-05:Although required by the harness instrument commonly issued by the Civil Aviation Safety Authority, the operator did not appraise shooting crews of the risks of using only a harness for restraint during low-level flight. Issue owner: Jayrow Helicopters Operation affected: Aviation: General aviation	Date, status, type Date: 26 Feb 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2019-025-SI-04Harness instrument clarity Number: AO-2019-025-SI-04 Description: AO-2019-025-SI-04:A harness instrument, commonly issued by the Civil Aviation Safety Authority (CASA), stated that a harness could be used instead of a seatbelt for take-off and landing. Although not intended by CASA, this instrument was easily able to be misinterpreted as indicating that a seatbelt was not required to be ... Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: General aviation	Date, status, type Date: 26 Feb 2021 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2019-025-SI-03Aerial platform shooter emergency training Number: AO-2019-025-SI-03 Description: AO-2019-025-SI-03:Recurrency training and drills in aircraft emergencies were not required for reissue of an aerial platform shooting permission. Some shooters last conducted training about 20 years prior, during initial issue of their permissions. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: General aviation	Date, status, type Date: 26 Feb 2021 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2019-025-SI-02 The Director of National Parks' risk management Number: AO-2019-025-SI-02 Description: AO-2019-025-SI-02 :The Director of National Parks did not actively manage the risk of the aerial culling task being conducted in the Kakadu National Park, or effectively supervise the operation. As a result, an increase in the number of crew, a change in helicopter type and change of helicopter operator all progressed ... Issue owner: Director of National Parks Operation affected: Aviation: General aviation	Date, status, type Date: 26 Feb 2021 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2019-025-SI-01Helmet provision and use Number: AO-2019-025-SI-01 Description: AO-2019-025-SI-01:Although the Director of National Parks’ safe operating procedures required shooters and spotters to wear helmets during aerial culling tasks, helmets were not provided or used on a routine basis. Issue owner: Aviation: General aviation Operation affected: Aviation: General aviation	Date, status, type Date: 26 Feb 2021 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2017-118-SI-04Fitment of recording devices in light aircraft - International Civil Aviation Organization Number: AO-2017-118-SI-04 Description: AO-2017-118-SI-04:Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents have been hampered by a lack of recorded data pertaining to the flight. This ... Issue owner: International Civil Aviation Organization Operation affected: Aviation: Air transport	Date, status, type Date: 29 Jan 2021 Status: Open – Safety action pending Type: Safety recommendation   Safety advisory notice   Safety recommendation
Issue, description, who it affects Issue: AO-2017-118-SI-01No regulatory requirement for carbon monoxide detectors Number: AO-2017-118-SI-01 Description: AO-2017-118-SI-01:There was no regulatory requirement from the Civil Aviation Safety Authority for piston‑engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: General aviation	Date, status, type Date: 29 Jan 2021 Status: Open – Safety action pending Type: Proactive action   Safety recommendation
Issue, description, who it affects Issue: AO-2017-118-SI-03Fitment of recording devices in light aircraft – Civil Aviation Safety Authority Number: AO-2017-118-SI-03 Description: AO-2017-118-SI-03:Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non‑identification ... Issue owner: Civil Aviation Safety Aviation Operation affected: Aviation: General aviation	Date, status, type Date: 25 Jan 2021 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2017-118-SI-02No monitoring for carbon monoxide detector serviceability Number: AO-2017-118-SI-02 Description: AO-2017-118-SI-02:Although detectors were not required to be fitted to their aircraft, Sydney Seaplanes had no mechanism for monitoring the serviceability of the carbon monoxide detectors. Issue owner: Sydney Seaplanes Operation affected: Aviation: General aviation	Date, status, type Date: 25 Jan 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2020-041-S1-01Maintenance Publications Number: AO-2020-041-S1-01 Description: AO-2020-041-S1-01:While the manufacturer's instructions for the zonal inspections detailed that installation blankets could be removed 'as necessary', they did not reference the insulation blanket installation procedure. This resulted in insulation blankets not being secured to the structure. Issue owner: Fokker Services Operation affected: Aviation: Maintenance	Date, status, type Date: 22 Jan 2021 Status: Open – Safety action pending Type: Proactive action   Proactive action   Proactive action   Proactive action
Issue, description, who it affects Issue: RO-2018-009-SI-01 Inspection processes Number: RO-2018-009-SI-01 Description: RO-2018-009-SI-01 :Pacific National’s inspection processes did not identify key structural points for inspection on RRYY class wagons, including the susceptibility to cracking in the junction between container loading outriggers, pull rod boxed opening, and the bottom centre sill sections. This reduced the likelihood of cracks being detected. Issue owner: Pacific National Operation affected: Rail: Freight	Date, status, type Date: 23 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2016-155-SI-01 Compressor turbine blade failure Number: AO-2016-155-SI-01 Description: AO-2016-155-SI-01 :Pratt & Whitney Canada (PWC) PT6A-114A engines fitted with compressor turbine vane rings that have been repaired in accordance with the United States Federal Aviation Administration‑approved scheme STI 72-50-254 have a significantly increased likelihood of CMSX-6 compressor turbine blade fracture and subsequent failure of the engine compared to those engines ... Issue owner: United States Federal Aviation Administration Operation affected: Aviation: Air transport	Date, status, type Date: 18 Dec 2020 Status: Open – Safety action pending Type: Proactive action   Proactive action   Proactive action   Proactive action   Proactive action   Proactive action
Issue, description, who it affects Issue: RO-2019-003-SI-01 Management of track lateral stability Number: RO-2019-003-SI-01 Description: RO-2019-003-SI-01 :The ARTC systems for managing track lateral stability did not lead to the location being managed as a location potentially vulnerable to instability. Issue owner: Australian rail Track Corporation Operation affected: Rail: Freight	Date, status, type Date: 16 Dec 2020 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2019-055-SI-02 Runway verification cues Number: AO-2019-055-SI-02 Description: AO-2019-055-SI-02 :Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway. Issue owner: Virgin Australia Airlines Operation affected: Aviation: Air transport	Date, status, type Date: 11 Dec 2020 Status: Open – Safety action pending
Issue, description, who it affects Issue: AO-2019-055-SI-01 Timing of 'before take-off' procedure Number: AO-2019-055-SI-01 Description: AO-2019-055-SI-01 :Virgin Australia Airlines did not require ATR flight crews to complete the Before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying ... Issue owner: Virgin Australia Airlines Operation affected: Aviation: Air transport	Date, status, type Date: 11 Dec 2020 Status: No longer relevant
Issue, description, who it affects Issue: RO-2018-008-SI-04Radial unitising straps not required in the Freight Loading Manual Number: RO-2018-008-SI-04 Description: RO-2018-008-SI-04:Pacific National's Freight Loading Manual did not require the use of radial unitising straps to prevent telescoping on jumbo coils where the thickness of the steel was greater than 2 mm. Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-008-SI-03Load restraint system Number: RO-2018-008-SI-03 Description: RO-2018-008-SI-03:Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose. Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Open – Safety action pending Type: Proactive action   Safety recommendation
Issue, description, who it affects Issue: RO-2018-008-SI-02Radial unitising straps contacting the cradle Number: RO-2018-008-SI-02 Description: RO-2018-008-SI-02:Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of ... Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: RO-2018-008-SI-01Rubber load mats not required in the Freight Loading Manual Number: RO-2018-008-SI-01 Description: RO-2018-008-SI-01:Pacific National's Freight Loading Manual, specific to the loading and unitising of jumbo coils, did not require the use of rubber load mat on cradles. Consequently, there was no requirement to consider the condition of load mat during inspection and maintenance. This allowed the continued use of cradles without load ... Issue owner: Pacific National Pty Ltd Operation affected: Rail: Freight	Date, status, type Date: 10 Dec 2020 Status: Closed – Adequately addressed Type: Proactive action