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Safety issues and actions

Issue, description, who it affects	Date, status, type
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: Partially addressed 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: 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
Issue, description, who it affects Issue: AO-2014-032-SI-03Reduced flight control tactile feedback Number: AO-2014-032-SI-03 Description: AO-2014-032-SI-03:The design of the ATR 72 pitch control system resulted in limited tactile feedback between the left and right control columns, reducing the ability of one pilot to detect that the other pilot is making control inputs. In addition, there were no visual or auditory systems to indicate dual control ... 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
Issue, description, who it affects Issue: RO-2016-006-SI-04Use of all available and reasonably practicable risk controls when parking trams Number: RO-2016-006-SI-04 Description: RO-2016-006-SI-04:STM did not require the application of all available and reasonably practicable risk controls when parking trams with respect to their location and handbrake application. Who it affects: Rolling Stock Operators Issue owner: Sydney Tramway Museum Operation affected: Rail: Operations control	Date, status, type Date: 17 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-006-SI-03Attending parked trams Number: RO-2016-006-SI-03 Description: RO-2016-006-SI-03:STM did not comply with its risk control in ensuring that trams were attended when parked. Who it affects: Sydney Tramway Museum Issue owner: Sydney Tramway Museum Operation affected: Rail: Operations control	Date, status, type Date: 17 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-006-SI-02 Change management process implementation for safety critical changes Number: RO-2016-006-SI-02 Description: RO-2016-006-SI-02 :STM did not follow its change management process for adopting the new hardwood chock type. Subsequently, the hardwood chock could not be applied reliably under the ‘J’ class wheel and could not restrict its movement. Who it affects: Rolling Stock Operators Issue owner: Sydney Tramway Museum Operation affected: Rail: Operations control	Date, status, type Date: 17 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2016-166-SI-04En route supplement guidance to flight crews Number: AO-2016-166-SI-04 Description: AO-2016-166-SI-04:The En Route Supplement Australia (ERSA) did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility. Who it affects: Pilots operating into Darwin airport Issue owner: Darwin International Airport Operation affected: Aviation: Airports	Date, status, type Date: 15 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2016-166-SI-03Operator guidance to flight crews Number: AO-2016-166-SI-03 Description: AO-2016-166-SI-03:Virgin Australia did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility. Who it affects: Virgin Australia Airlines flight crews operating into Darwin airport Issue owner: Virgin Australia Airlines Operation affected: Aviation: Air transport	Date, status, type Date: 15 May 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2016-166-SI-02Limited visual cues for approach at Darwin runway 11/29 Number: AO-2016-166-SI-02 Description: AO-2016-166-SI-02:The absence of centreline lighting and the 60-m width of runway 11/29 at Darwin result in very limited visual cues for maintaining runway alignment during night landings in reduced visibility. Who it affects: Pilots operating into Darwin airport Issue owner: Darwin International Airport Operation affected: Aviation: Airports	Date, status, type Date: 15 May 2019 Status: Safety action pending Type: Recommendation
Issue, description, who it affects Issue: AO-2016-166-SI-01Standards for installation of runway centreline lighting on wider runways Number: AO-2016-166-SI-01 Description: AO-2016-166-SI-01:Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions. The installation of centreline lighting on wider category I runways is recommended but not mandated by the International Civil Aviation Organization Annex 14. Who it affects: Operators using runways wider than 50 m without centreline lighting Issue owner: International Civil Aviation Organization Operation affected: Aviation: Airports	Date, status, type Date: 15 May 2019 Status: Safety action pending Type: Recommendation
Issue, description, who it affects Issue: AO-2015-107-SI-02NAV ADR DISAGREE procedure Number: AO-2015-107-SI-02 Description: AO-2015-107-SI-02:A NAV ADR DISAGREE alert can be triggered by either an airspeed discrepancy, or angle of attack discrepancy. The alert does not identify which, and the associated procedure may lead flight crews to incorrectly diagnosing the source of the alert when the airspeed is erroneous for a short period and ... Who it affects: Operators of Airbus A320 aircraft Issue owner: Airbus Operation affected: Aviation: Air transport	Date, status, type Date: 04 Apr 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2015-107-SI-01Priority of NAV ADR DISAGREE alert Number: AO-2015-107-SI-01 Description: AO-2015-107-SI-01:Although the NAV ADR DISAGREE had more immediate safety implications relating to unreliable airspeed, the ECAM alert priority logic placed this alert below the engine-related faults. As a result, the NAV ADR DISAGREE alert was not immediately visible to the flight crew due to the limited space available on the ... Who it affects: Operators of Airbus A320 aircraft Issue owner: Airbus Operation affected: Aviation: Air transport	Date, status, type Date: 04 Apr 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-044-SI-02Re-evaluating hold speeds for a change in altitude Number: AO-2017-044-SI-02 Description: AO-2017-044-SI-02:The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude. Who it affects: Qantas Airways Boeing 747 flight crew Issue owner: Qantas Airways Operation affected: Aviation: Air transport	Date, status, type Date: 27 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-044-SI-01Stall prevention and recovery at high altitudes Number: AO-2017-044-SI-01 Description: AO-2017-044-SI-01:The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle. Who it affects: Qantas Airways Boeing 747 flight crew Issue owner: Qantas Airways Operation affected: Aviation: Air transport	Date, status, type Date: 27 Mar 2019 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2016-001-SI-03Maintenance response to recurring track defects in areas with a degraded formation Number: RO-2016-001-SI-03 Description: RO-2016-001-SI-03:A more stringent maintenance response than that for an isolated track geometry defect was not considered or implemented in accordance with ARTC’s COP. A more stringent maintenance response should have been implemented given the degraded formation and the track’s rapid deterioration between 12-14 January 2016, two days prior to the ... Who it affects: Rail Infrastructure Managers (RIMs) Issue owner: Australian Rail Track Corporation (ARTC) Operation affected: Rail: Infrastructure	Date, status, type Date: 25 Mar 2019 Status: Adequately addressed Type: Proactive Action