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Safety issues and actions

Issue, description, who it affects	Date, status, type
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
Issue, description, who it affects Issue: AO-2017-069-SI-01 Angel Flight Australia consideration of commercial flights Number: AO-2017-069-SI-01 Description: AO-2017-069-SI-01 :Angel Flight did not consider the safety benefits of commercial passenger flights when suitable flights were available. 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: Recommendation
Issue, description, who it affects Issue: RO-2017-009-SI-02Single source of information for Lookout Working prohibition Number: RO-2017-009-SI-02 Description: RO-2017-009-SI-02:Lookout Working (LOW) was implemented in an area deemed unsuitable for LOW on the Sydney Trains Worksite Protection Hazardous Locations Register (WPHLR). This is likely due to the WPHLR not being clearly stated as a reference with specific requirements that must be adhered to. Who it affects: All track managers Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 25 Jul 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-009-SI-01Use of warning lights Number: RO-2017-009-SI-01 Description: RO-2017-009-SI-01:Warning lights were utilised at Tempe to overcome sighting hazards and justify the use of Lookout Working (LOW). Warning lights rely on lookouts maintaining continuous observation and their use were not specifically referenced in the LOW Network Rules. Who it affects: All track managers Issue owner: Sydney Trains Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 25 Jul 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-005-SI-02Management of rail stress Number: RO-2018-005-SI-02 Description: RO-2018-005-SI-02:A variety of techniques to indicate and record rail stress at specific locations are available, however, Aurizon had not used any of these techniques in some locations with elevated risk of rail stress, such as tangent track on steep grades. As a result, Aurizon could not readily determine the presence ... Who it affects: Train crew and passengers on board trains on Aurizon-owned track Issue owner: Aurizon Operation affected: Rail: Infrastructure	Date, status, type Date: 28 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2018-005-SI-01Use of hazard location register Number: RO-2018-005-SI-01 Description: RO-2018-005-SI-01:When planning track disturbing work, Aurizon’s normal practice was to use its Hazard Location Register as a record of past occurrences at a specific location. Aurizon did not use the Hazard Location Register as a resource to consider the situational characteristics of a location that may increase risk, such as ... Who it affects: Train crew and passengers on board trains on Aurizon-owned track Issue owner: Aurizon Operation affected: Rail: Infrastructure	Date, status, type Date: 28 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-009-SI-04Hydrographic use of point features Number: MO-2017-009-SI-04 Description: MO-2017-009-SI-04:The hydrographic use of point feature objects to represent physical features of relatively significant spatial extent on an Electronic Navigational Chart can increase the risk of the hazard posed by such features being misinterpreted by mariners and potentially reduce the effectiveness of the ECDIS safety checking functions. Who it affects: Vessels using Australian Electronic Navigational Charts Issue owner: Australian Hydrographic Office Operation affected: Marine: Shore-based operations	Date, status, type Date: 27 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-009-SI-03ECDIS software Number: MO-2017-009-SI-03 Description: MO-2017-009-SI-03:ECDIS on board most Australian Border Force cutters, including ABFC Roebuck Bay, operated with a non-type-approved naval software version that was not updated to the latest applicable standards of the International Hydrographic Organization. The ECDIS therefore did not comply with the minimum requirements of an ECDIS being used to meet ... Who it affects: Operators of Australian Border Force cutters Issue owner: Australian Border Force Operation affected: Marine: Shipboard operations	Date, status, type Date: 27 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-009-SI-02Vessel survey and certification Number: MO-2017-009-SI-02 Description: MO-2017-009-SI-02:Most Australian Border Force cutters, including ABFC Roebuck Bay, were installed with ECDIS operating on non-type-approved naval software. Subsequently, DNV GL, acting on behalf of the Australian Maritime Safety Authority, incorrectly certified these vessels as using type-approved ECDIS to meet the chart carriage requirements of the regulations. This removed an ... Who it affects: Australian flagged vessels Issue owner: Australian Maritime Safety Authority Operation affected: Marine: Shore-based operations	Date, status, type Date: 27 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: MO-2017-009-SI-01ECDIS familiarisation Number: MO-2017-009-SI-01 Description: MO-2017-009-SI-01:Although the online VisionMaster FT ECDIS type-specific familiarisation training included the relevant content, the training as undertaken by Australian Border Force deck officers was not effective in preparing ABFC Roebuck Bay's officers for the operational use of the ECDIS. Who it affects: Australian Border Force deck officers Issue owner: Australian Border Force Operation affected: Marine: Shipboard operations	Date, status, type Date: 27 Jun 2019 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-007-SI-01 QR’s track monitoring and inspection processes Number: RO-2017-007-SI-01 Description: RO-2017-007-SI-01 :Queensland Rail’s track monitoring and inspection processes were not effective in identifying significant deterioration in the condition of level crossing ID 2309 and its approach roads to ensure the safe operating limits of the level crossing throughout its lifecycle. Who it affects: Rail Infrastructure Managers, Rail Operators and Road Authorities/Managers Issue owner: Queensland Rail Operation affected: Rail: Infrastructure	Date, status, type Date: 25 Jun 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-013-SI-02Axle fatigue susceptibility Number: RO-2017-013-SI-02 Description: RO-2017-013-SI-02:The GATX 840P1 axle was susceptible to fatigue cracking due to relatively minor damage that was not reliably detected prior to failure. Who it affects: All users of 840P1 axles Issue owner: Incitec Pivot Limited Operation affected: Rail: Rolling stock	Date, status, type Date: 12 Jun 2019 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: RO-2017-013-SI-01Magnetic particle inspection Number: RO-2017-013-SI-01 Description: RO-2017-013-SI-01:Anomalies in the magnetic particle inspection procedures likely led to the crack not being detected. Who it affects: All workers conducting magnetic particle inspection Issue owner: Aurizon Operation affected: Rail: Rolling stock	Date, status, type Date: 12 Jun 2019 Status: Safety action pending Type: Proactive Action   Recommendation
Issue, description, who it affects Issue: AO-2014-032-SI-08Undetected horizontal stabiliser damage in world fleet Number: AO-2014-032-SI-08 Description: AO-2014-032-SI-08:As a legacy of there being no inspection specific to an in-flight pitch disconnect, there is potential for other ATR aircraft to have sustained an in-flight pitch disconnect in the past and be operating with undetected horizontal stabiliser damage. Who it affects: All operators of ATR 42 and ATR 72 aircraft Issue owner: ATR Operation affected: Aviation: Air transport	Date, status, type Date: 24 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2014-032-SI-07Maintenance requirements following an in-flight pitch disconnect Number: AO-2014-032-SI-07 Description: AO-2014-032-SI-07:The aircraft manufacturer, ATR, did not provide a maintenance inspection to specifically assess the effect of an in-flight pitch disconnect on the structural integrity of the horizontal stabilisers. As a result, if an in-flight pitch disconnect occurred, the aircraft may not be inspected at a level commensurate with the criticality ... Who it affects: All operators of ATR 42 and ATR 72 aircraft Issue owner: ATR Operation affected: Aviation: Air transport	Date, status, type Date: 24 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2014-032-SI-06No consideration of dual control inputs on aircraft response in the design standard Number: AO-2014-032-SI-06 Description: AO-2014-032-SI-06:Although the design standard for the aircraft (JAR-25) required the control system to be of sufficient strength to withstand dual control inputs, it did not require consideration of the effect that dual control inputs may have on control of the aircraft. Similarly, the current design standard (CS-25) does not address ... Who it affects: All operators of ATR 42 and ATR 72 aircraft Issue owner: European Aviation Safety Agency (EASA) Operation affected: Aviation: Air transport	Date, status, type Date: 24 May 2019 Status: Safety action pending Type: Recommendation
Issue, description, who it affects Issue: AO-2014-032-SI-05No consideration of transient control loads in the design standard Number: AO-2014-032-SI-05 Description: AO-2014-032-SI-05:The design standard for large transport aircraft, Joint Aviation Requirements - Part 25 (JAR-25), did not require that the demonstrated potential for flexibility in the control system to develop transient dynamic loads, be considered during certification. Similarly, the current certification standard for Large Aeroplanes (CS-25) does not address this issue. Who it affects: All operators of ATR 42 and ATR 72 aircraft Issue owner: European Aviation Safety Agency (EASA) Operation affected: Aviation: Air transport	Date, status, type Date: 24 May 2019 Status: Safety action pending Type: Proactive Action
Issue, description, who it affects Issue: AO-2014-032-SI-04Effect of dual control inputs on elevator response Number: AO-2014-032-SI-04 Description: AO-2014-032-SI-04:Flexibility in the ATR 72’s pitch control system between the control columns results in a change in the aircraft’s longitudinal handling qualities and control dynamics when dual control inputs are made. This could result in an aircraft-pilot coupling event where flight crew may find it difficult to control the aircraft. Who it affects: All operators of ATR 42 and ATR 72 aircraft Issue owner: ATR Operation affected: Aviation: Air transport	Date, status, type Date: 24 May 2019 Status: Safety action pending Type: Recommendation