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Safety issues and actions

Issue, description, who it affects	Date, status, type
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
Issue, description, who it affects Issue: AO-2017-005-SI-01Operator’s procedures and practices for airborne inspections of a landing area Number: AO-2017-005-SI-01 Description: AO-2017-005-SI-01:The operator normally conducted airborne inspections of the Middle Island aeroplane landing area at about 50–100 ft while flying at normal cruise speed towards an area of water, and its procedures did not ensure the effective management of the risk of an engine failure or power loss when at a ... 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: RO-2018-019-SI-01Wiring error was not detected Number: RO-2018-019-SI-01 Description: RO-2018-019-SI-01:The wiring error was not detected by Metro Train Melbourne’s (MTM) verification program. Who it affects: Passenger rail transport operations Issue owner: Metro Trains Melbourne Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 09 Oct 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-015-SI-01Process control Number: RO-2018-015-SI-01 Description: RO-2018-015-SI-01:V/Line did not have a documented detailed process for inhibiting and reinstating level crossing protection equipment. Who it affects: Rail: Passenger - regional Issue owner: V/Line Operation affected: Rail: Passenger - regional	Date, status, type Date: 08 Oct 2019 Status: Adequately addressed Type: Proactive Action
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