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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2018-078-SI-03Regulatory management of repeat safety findings Number: AO-2018-078-SI-03 Description: AO-2018-078-SI-03:The Civil Aviation Safety Authority’s acquittal process for repeat safety findings was not effective in ensuring that all previous findings of a similar nature were also appropriately assessed prior to the current and all associated safety findings being acquitted. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Air transport	Date, status, type Date: 20 Dec 2021 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2018-078-SI-02 Hazard identification Number: AO-2018-078-SI-02 Description: AO-2018-078-SI-02 :Airlines of Tasmania's safety management processes for identifying hazards extensively relied on safety reports. This limited the opportunity to proactively identify the risks in all operational activities, and assess the effectiveness of any controls in place. Issue owner: Airlines of Tasmania [Par Avion] Operation affected: Aviation: Air transport	Date, status, type Date: 20 Dec 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-078-SI-01South-west operations guidance Number: AO-2018-078-SI-01 Description: AO-2018-078-SI-01:Airlines of Tasmania did not provide any documented guidance for the south-west operations, despite encouraging pilots to commence the flight, even when forecasts indicated they may be likely to encounter adverse weather en route. This resulted in the pilots having varied understanding of the expectations regarding in‑flight weather‑related decision making ... Issue owner: Airlines of Tasmania Operation affected: Aviation: Air transport	Date, status, type Date: 20 Dec 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-018-SI-03Inconsistencies with application of fatigue management system Number: RO-2019-018-SI-03 Description: RO-2019-018-SI-03:There were inconsistences with Sydney Trains’ application of their fatigue management system, in particular the the use of a bio-mathematical model to predict individual fatigue risk. (Safety issue) Issue owner: Sydney Trains Operation affected: Rail: Operations control	Date, status, type Date: 20 Dec 2021 Status: Closed – Adequately addressed
Issue, description, who it affects Issue: RO-2019-018-SI-02Signaller supervision Number: RO-2019-018-SI-02 Description: RO-2019-018-SI-02:Sydney Trains did not provide supervision at Granville signal box to ensure there was adequate coverage on both signalling panels. (Safety issue) Issue owner: Sydney Trains Operation affected: Rail: Operations control	Date, status, type Date: 20 Dec 2021 Status: Closed – Adequately addressed
Issue, description, who it affects Issue: RO-2019-018-SI-01The ASB rule and procedure for using an alternative route Number: RO-2019-018-SI-01 Description: RO-2019-018-SI-01:The ASB rule NWT 308 and procedure NPR 703 did not provide sufficient description for the task of using protecting signals for an alternative route. (Safety issue) Issue owner: Sydney Trains Operation affected: Rail: Operations control	Date, status, type Date: 20 Dec 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2021-031-SI-02Risk assessment for lifting operations Number: AO-2021-031-SI-02 Description: AO-2021-031-SI-02:GHD's documented risk assessment for helicopter operations did not consider the hazard of an emergency landing at the drill site. This increased the risk that ground personnel were not clear of the load pick-up area in the event an emergency landing was required. Issue owner: GHD Limited Operation affected: Aviation: General aviation	Date, status, type Date: 16 Dec 2021 Status: Closed – Adequately addressed Type: Proactive action   Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2021-031-SI-01Maintenance practices and processes Number: AO-2021-031-SI-01 Description: AO-2021-031-SI-01:Encore Aviation's maintenance practices and processes related to inspections, record keeping and trend monitoring, were likely inadequate to detect the potential impending failure of safety critical components. Issue owner: Encore Aviation – Aircraft maintenance provider Operation affected: Aviation: Maintenance	Date, status, type Date: 16 Dec 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2020-027-S1-02Guidance in the ground handling manual Number: AO-2020-027-S1-02 Description: AO-2020-027-S1-02:The operator's ground handling manual did not contain detailed procedural guidance for facilitating accurate redistribution of freight and ensure that an aircraft would be correctly loaded. Issue owner: Toll Aviation Operation affected: Aviation: Air transport	Date, status, type Date: 09 Dec 2021 Status: Type: Proactive action
Issue, description, who it affects Issue: RO-2020-019-SI-01Absence of authority-overrun protection Number: RO-2020-019-SI-01 Description: RO-2020-019-SI-01:The absence of authority-overrun protection (such as TPWS) at signal SST535 increased the potential consequences of a SPAD. Issue owner: V/Line Corporation Operation affected: Rail: Passenger - regional	Date, status, type Date: 07 Dec 2021 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2019-026-SI-02Fatigue damage detection inspection requirements Number: AO-2019-026-SI-02 Description: AO-2019-026-SI-02:Following an assessment of historical data, the aircraft manufacturer, Textron Aviation, replaced a flight hour based repetitive eddy current inspection for cracking of the carry-through structure with a three-yearly visual corrosion inspection for all operation types. This significantly limited the opportunities to identify fatigue cracking within the carry-through structure of ... Issue owner: Textron Aviation Operation affected: Aviation: General aviation	Date, status, type Date: 23 Nov 2021 Status: Open – Safety action pending Type: Proactive action   Safety recommendation   Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2020-013-SI-01Compliance with AD SUPP 10 Number: AO-2020-013-SI-01 Description: AO-2020-013-SI-01:It is likely that specific post-flight inspection requirements for the Breeze Eastern rescue hoist listed in Airworthiness Directive AD/SUPP/10 were not adequately completed by the operator. The inspections were targeted at ensuring correct stowage of the hook assembly at the end of each flight. Issue owner: New South Wales National Parks and Wildlife Service (ParkAir) Operation affected: Aviation: Other	Date, status, type Date: 21 Oct 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2020-002-SI-02 Regulator guidance Number: AO-2020-002-SI-02 Description: AO-2020-002-SI-02 :Civil Aviation Safety Authority (CASA) advisory publications did not include information regarding the potential for reduction in braking performance resulting from active rainfall. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Air transport	Date, status, type Date: 01 Sep 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2020-002-SI-01 Operator guidance Number: AO-2020-002-SI-01 Description: AO-2020-002-SI-01 :The operator's documentation required crew to consider contamination of runways at the departure and destination airports. However, the provided definition and guidance did not include the means to identify water contamination from active rainfall. Issue owner: Network Aviation Operation affected: Aviation: Air transport	Date, status, type Date: 01 Sep 2021 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2020-010-SI-02 Cabin exit design criteria (Issue owner: United States Federal Aviation Administration) Number: AO-2020-010-SI-02 Description: AO-2020-010-SI-02 :Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities. Issue owner: United States Federal Aviation Administration Operation affected: Aviation: Air transport	Date, status, type Date: 08 Jul 2021 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2020-010-SI-01 Cessna 206 emergency procedures Number: AO-2020-010-SI-01 Description: AO-2020-010-SI-01 :The Cessna 206 procedure for ditching and forced landing states that the flaps are to be extended to 40°. While that permits the aircraft to land at a slower speed, it also significantly restricts emergency egress via the cargo door. However, there is no warning about that aspect in the ... Issue owner: Textron Aviation Operation affected: Aviation: Air transport	Date, status, type Date: 08 Jul 2021 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2020-010-SI-02 Cabin exit design criteria (Issue owner: Civil Aviation Safety Authority) Number: AO-2020-010-SI-02 Description: AO-2020-010-SI-02 :Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Air transport	Date, status, type Date: 08 Jul 2021 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: AO-2020-036-SI-01 Maintenance manual supplement Number: AO-2020-036-SI-01 Description: AO-2020-036-SI-01 :The inspection procedures in the West Star Aviation maintenance manual supplement for extended life program Cessna 441 aircraft were inadequate to detect the progressive disbonding of the emergency exit door. Issue owner: West Star Aviation Operation affected: Aviation: Maintenance	Date, status, type Date: 30 Jun 2021 Status: Closed – Adequately addressed Type: Proactive action   Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2018-026-SI-01Operator consolidation processes for flight crew Number: AO-2018-026-SI-01 Description: AO-2018-026-SI-01:Although the operator complied with the regulatory requirements for training and experience of pilots, it had limited processes in place to ensure pilots with minimal time and experience on a new and technically different helicopter type had the opportunity to effectively consolidate their skills on the type required for conducting ... Issue owner: Whitsunday Air Services Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2021 Status: Closed – Adequately addressed Type: Proactive action   Proactive action
Issue, description, who it affects Issue: AO-2018-026-SI-07Pilots leaving the controls of the helicopter Number: AO-2018-026-SI-07 Description: AO-2018-026-SI-07:It was common practice for the operator’s pilots to leave the controls of their helicopter, while the rotors were turning and the friction locks applied, to escort passengers to and from the helicopter. Issue owner: Whitsunday Air Services Operation affected: Aviation: Air transport	Date, status, type Date: 16 Jun 2021 Status: Closed – Partially addressed Type: Proactive action