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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2018-006-SI-02Pilot’s operating handbook Number: AO-2018-006-SI-02 Description: AO-2018-006-SI-02:The Robinson R44 pilot’s operating handbook low rotor RPM recovery procedure did not include reference to the minimum power airspeed for the helicopter as a consideration, which may assist a pilot to recover from a low rotor RPM condition. Issue owner: Robinson Helicopter Company Operation affected: Aviation: Air transport	Date, status, type Date: 07 Oct 2020 Status: Open – Safety action pending Type: Proactive action   Safety recommendation
Issue, description, who it affects Issue: AO-2018-006-SI-01Passenger scales Number: AO-2018-006-SI-01 Description: AO-2018-006-SI-01:Professional Helicopter Services did not have a calibration schedule for their passenger scales, which were under-reading. This increased the risk of their helicopters not achieving their expected take-off performance. Issue owner: Professional Helicopter Services Operation affected: Aviation: Air transport	Date, status, type Date: 07 Oct 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-032-SI-03Inhibition of safety alerts for combined air traffic control roles Number: AO-2018-032-SI-03 Description: AO-2018-032-SI-03:Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combined roles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation ... Who it affects: Tower controllers at Perth Airport Issue owner: Airservices Australia Operation affected: Aviation: Airspace management	Date, status, type Date: 01 Oct 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-032-SI-02Location and design of taxiway J2 at Perth Airport Number: AO-2018-032-SI-02 Description: AO-2018-032-SI-02:The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient ... Who it affects: All flight crew and operators of jet aircraft using runway 03 at Perth Airport Issue owner: Perth Airport Pty Ltd Operation affected: Aviation: Air transport	Date, status, type Date: 01 Oct 2020 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2018-032-SI-01Operator guidance for flight crew briefing of aerodrome hot spots Number: AO-2018-032-SI-01 Description: AO-2018-032-SI-01:Although Qantas provided detailed guidance to flight crews about the content of departure and approach briefings, it did not specifically require aerodrome hot spots to be briefed. Who it affects: All of the operator’s flight crew Issue owner: Qantas Airways Operation affected: Aviation: Air transport	Date, status, type Date: 01 Oct 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-002-SI-01No specific instructions provided Number: RO-2019-002-SI-01 Description: RO-2019-002-SI-01:VicTrack’s contractor, UGL Engineering Limited, did not provide signalling testers with specific instructions detailing the scope of work to be conducted at each stage of a project, but rather, only provided packaged isolation plans for the entire project. The absence of these instructions increased the risk of the works being ... Issue owner: VicTrack Operation affected: Rail: Infrastructure	Date, status, type Date: 22 Sep 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-049-SI-01Unclear procedures in Aircraft Maintenance Manual Number: AO-2018-049-SI-01 Description: AO-2018-049-SI-01:The procedures in the aircraft maintenance manual relating to chip detector debris analysis were written in a way that could cause confusion and error. This probably influenced the actions of the maintenance personnel to release the aircraft to service with a deteriorating bearing. Issue owner: Pratt & Whitney Canada Operation affected: Aviation: Maintenance	Date, status, type Date: 16 Sep 2020 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: MO-2018-004-SI-001Critical spares Number: MO-2018-004-SI-001 Description: MO-2018-004-SI-001:No procedure or system was in place to ensure critical spares were identified and their inventory controlled to ensure availability when required. As a consequence, the fan belts for the emergency generator had been on order for several months. Issue owner: Kowa Marine Service Operation affected: Marine: Shipboard operations	Date, status, type Date: 11 Sep 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-011-SI-03Process for co-ordinating network control activities during an emergency response Number: RO-2018-011-SI-03 Description: RO-2018-011-SI-03:Queensland Rail did not have an effective process in place to ensure that safety-critical actions were co-ordinated and completed when multiple network control officers were involved in responding to an overhead line equipment emergency.   Issue owner: Queensland Rail Operation affected: Rail: Operations control	Date, status, type Date: 01 Sep 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2018-011-SI-02Access to QR procedures and existence of Aurizon documents Number: RO-2018-011-SI-02 Description: RO-2018-011-SI-02:Aurizon did not provide drivers with ready access to Queensland Rail’s procedures for driver only operations and overhead line equipment emergencies when they were operating on the Queensland Rail network. In addition, Aurizon did not have procedures for driver only operations that applied to its own network. Issue owner: Aurizon Operation affected: Rail: Freight	Date, status, type Date: 01 Sep 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2018-011-SI-01Unusual loads responsibilities and guidance material Number: RO-2018-011-SI-01 Description: RO-2018-011-SI-01:Aurizon did not have an effective system in place for ensuring personnel required to check the securing of unusual loads (such as empty flat racks) prior to departure had sufficient knowledge of their responsibilities, and had ready access to relevant procedures, guidance and checklists. Issue owner: Aurizon Operation affected: Rail: Freight	Date, status, type Date: 01 Sep 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2018-027-SI-01 Balloon visual meteorological conditions Number: AO-2018-027-SI-01 Description: AO-2018-027-SI-01 :The visual flight rules permitted balloons to arrive and depart in foggy conditions without assurance that sufficient visibility existed to see and avoid obstacles. Who it affects: All balloon operators of charter flights Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Other	Date, status, type Date: 11 Aug 2020 Status: Open – Safety action pending Type: Proactive action   Safety recommendation
Issue, description, who it affects Issue: AO-2017-078-SI-01Maintenance practices Number: AO-2017-078-SI-01 Description: AO-2017-078-SI-01:Cloncurry Air Maintenance had adopted a number of practices, which included using abbreviated inspection checklists, not recording all flight control disturbances and not progressively certifying for every inspection item as the work was completed, which increased the risk of memory-related errors and the omission of tasks. Who it affects: Cloncurry Air Maintenance Issue owner: Cloncurry Air Maintenance Operation affected: Aviation: Maintenance	Date, status, type Date: 21 Jul 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-007-SI-04Procedures for sharing workload in two-driver operation Number: RO-2018-007-SI-04 Description: RO-2018-007-SI-04:Aurizon’s procedures and guidance for two-driver operation during situations such as a condition affecting the network (CAN) did not facilitate the effective sharing of duties and teamwork to minimise the potential effects of degraded conditions on driver workload and fatigue. Who it affects: The operator’s train crew Issue owner: Aurizon Operation affected: Rail: Freight	Date, status, type Date: 30 Jun 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2018-007-SI-03Application of a controlled speed requirement by network control Number: RO-2018-007-SI-03 Description: RO-2018-007-SI-03:Queensland Rail did not have any restrictions on the distance or time that controlled speed could be used as a risk control for safe train operation in situations such as a condition affecting the network (CAN). The effectiveness of controlled speed has the significant potential to deteriorate over extended time ... Who it affects: Network control Issue owner: Queensland Rail Operation affected: Rail: Operations control	Date, status, type Date: 30 Jun 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2018-007-SI-02Procedures for actively monitoring conditions ahead of a train Number: RO-2018-007-SI-02 Description: RO-2018-007-SI-02:Queensland Rail did not have procedures that required network control personnel to actively search for information about track conditions ahead of a train during situations such as a condition affecting the network (CAN), when conditions had the realistic potential to have deteriorated since the last patrol or train had run ... Who it affects: Network control Issue owner: Queensland Rail Operation affected: Rail: Operations control	Date, status, type Date: 30 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-007-SI-01Advice of weather monitoring station serviceability Number: RO-2018-007-SI-01 Description: RO-2018-007-SI-01:Queensland Rail did not have an effective means of ensuring that, during situations such as a condition affecting the network (CAN), network control personnel were aware of the relevant weather monitoring systems that were unserviceable. Who it affects: Network control Issue owner: Queensland Rail Operation affected: Rail: Operations control	Date, status, type Date: 30 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-021-SI-01 Sydney Trains’ Control of worksite access and egress Number: RO-2018-021-SI-01 Description: RO-2018-021-SI-01 :Sydney Trains' control of the access and egress to the project worksite did not ensure that all workers entering the worksite were identified and received an induction. Who it affects: All rail infrastructure managers Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 30 Jun 2020 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2017-066-SI-02Inspection period for blade cracking Number: AO-2017-066-SI-02 Description: AO-2017-066-SI-02:The scheduled inspections recommended by Rolls-Royce to detect cracking in Trent 700 fan blades, were insufficient to detect early onset fatigue cracks in the membrane to panel bond before those cracks could progress to failure. Who it affects: Air transport operators whose aircraft are fitted with Trent 700 engines. Issue owner: Rolls-Royce plc Operation affected: Aviation: Air transport	Date, status, type Date: 30 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2017-066-SI-01Fatigue cracking of Trent 700 fan blades Number: AO-2017-066-SI-01 Description: AO-2017-066-SI-01:The Trent 700 blade manufacturing process produced a variation in internal membrane-to-panel acute corner geometry that, in combination with the inherent high level of blade panel stress, could lead to increased localised stresses in those corner areas and the initiation and propagation of fatigue cracking. Who it affects: Air transport operators whose aircraft are fitted with Trent 700 engines. Issue owner: Rolls-Royce plc Operation affected: Aviation: Air transport	Date, status, type Date: 30 Jun 2020 Status: Closed – Adequately addressed Type: Proactive action