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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2019-073-SI-05 Procedure for a rapid disembarkation
Number: AO-2019-073-SI-05
Description: AO-2019-073-SI-05 :Qantas did not have a procedure for a rapid disembarkation, or other similar procedure that would effectively enable rapid deplaning at a slower and more controlled pace than an emergency evacuation. Therefore, the only option for rapid deplaning was an emergency evacuation utilising slides, which unnecessarily increased the risk of ...
Issue owner: Qantas Airways Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 21 Jun 2022
Status: Open – Safety action pending
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2019-073-SI-02 Cabin crew training
Number: AO-2019-073-SI-02
Description: AO-2019-073-SI-02 :Qantas's cabin crew recurrent training did not include any situation whereby a disarmed door would have to be rearmed in an emergency. This increased the likelihood that a door would be opened without the escape slide deployed, reducing the number of available exits.
Issue owner: Qantas Airways Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 21 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2019-073-SI-01 Evacuation commands
Number: AO-2019-073-SI-01
Description: AO-2019-073-SI-01 :Qantas's cabin crew primary evacuation commands did not include phrases such as 'leave everything behind' and 'jump and slide'; instead, these phrases were optional. Consequently, passengers would generally not receive specific guidance until they reached an exit, which would likely slow down the evacuation.
Issue owner: Qantas Airways Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 21 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2019-073-SI-03 Passenger safety information
Number: AO-2019-073-SI-03
Description: AO-2019-073-SI-03 :Qantas’s method of briefing passengers provided limited and inconsistent information about how to use the escape slides safely and what to do with cabin baggage in an emergency.
Issue owner: Qantas Airways Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 21 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-01Risk controls associated with pilots identifying fatigue risks associated with insufficient sleep and extended wakefulness
Number: AO-2018-022-SI-01
Description: AO-2018-022-SI-01:The sleep log tool used by the operator contained a coding error and it also pre-loaded sleep periods of future nights by default. This combination of factors reduced the likelihood pilots would identify fatigue risks associated with insufficient sleep and extended wakefulness.
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-02Use of sleep reporting spreadsheet and potential for modification of data input to meet operator’s minimum requirements
Number: AO-2018-022-SI-02
Description: AO-2018-022-SI-02:The operator's fatigue risk management system relied extensively on a sleep reporting spreadsheet (sleep log) that was based on the prior sleep wake model, and the spreadsheet had a transparent rule set that made the recorded data easy to modify to achieve results that met the operator’s minimum sleep and ...
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-04Operator’s circuit and approach procedures for marine pilot transfer operations and criteria for achieving a stabilised approach
Number: AO-2018-022-SI-04
Description: AO-2018-022-SI-04:The operator’s circuit and approach procedures for marine pilot transfer operations did not minimise pilot workload or provide the recommended stabilised approach criteria with mandatory go-around policy. These procedures could allow a combination of conditions that increased the risk of a sustained abnormal flight path and collision with terrain/water.
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-005Operator’s training and assessing procedures for marine pilot transfer operations in degraded visual cueing environments
Number: AO-2018-022-SI-005
Description: AO-2018-022-SI-005:The operator's training and assessing procedures for marine pilot transfer operations did not provide assurance that pilot under supervision experience, helicopter instrumentation, and instructor capability were suitable for line training at night in a degraded visual cueing environment.
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-03Configuration of instrument panel for instructor or training/check pilot in degraded visual cueing environments
Number: AO-2018-022-SI-03
Description: AO-2018-022-SI-03:The instrument panels fitted to VH-ZGA and the operator's other EC135 helicopter at Port Hedland were equipped for single-pilot operation under the instrument flight rules. When used for flight training or checking in a degraded visual cueing environment, this configuration has a detrimental effect on the ability of an instructor ...
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2019-063-SI-03Organisational change
Number: AO-2019-063-SI-03
Description: AO-2019-063-SI-03:Changes in the operator's key safety post holder positions, safety reporting systems and internal processes reduced effective safety assurance.
Issue owner: Alliance Airlines Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-063-SI-02 Flight crew training
Number: AO-2019-063-SI-02
Description: AO-2019-063-SI-02 :The operator’s training for the Fokker F28-Mk0100 did not prepare pilots for alpha mode activation during critical phases of flight.
Issue owner: Alliance Airlines Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-063-SI-01Safety management reporting system
Number: AO-2019-063-SI-01
Description: AO-2019-063-SI-01:The operator’s safety management reporting system did not enable the effective prioritisation of submitted safety reports.
Issue owner: Alliance Airlines Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2021-023-SI-01Inadequate traffic alert and collision avoidance training
Number: AO-2021-023-SI-01
Description: AO-2021-023-SI-01:The helicopter operator's traffic alert and collision avoidance system knowledge was inadequate with respect to resolution advisory alert terrain considerations and the required intensity of response manoeuvring.
Issue owner: Babcock Mission Critical Services Australia
Operation affected: Aviation: General aviation
Date, status, type
Date: 27 May 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2020-038-SI-01External aircraft white lighting
Number: AO-2020-038-SI-01
Description: AO-2020-038-SI-01:The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height., This delayed the identification and recovery from the unsafe aircraft state resulting in the pilot not identifying the developing rate of descent during the incident, delaying ...
Issue owner: Helicorp Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 08 Apr 2022
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: AO-2020-012-SI-01ERSA procedure
Number: AO-2020-012-SI-01
Description: AO-2020-012-SI-01:The En-Route Supplement Australia included a requirement to add 1,000 ft to the prescribed practice instrument approach ‘altitude’ at Mangalore Airport. The procedure did not detail whether this height was to be applied to the minimum descent altitude or to all approach altitudes, resulting in varied application and an increased ...
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 31 Mar 2022
Status: Open – Safety action pending
Type: Safety recommendation
Issue, description, who it affects
Issue: AO 2020 062 SI 01Ballina airport safety review
Number: AO 2020 062 SI 01
Description: AO 2020 062 SI 01:The Civil Aviation Safety Authority review of the airspace surrounding Ballina Byron Gateway Airport did not include data for aircraft transiting the airspace without using the airport. Therefore, the risk associated with occurrences such as this one were not specifically considered when assessing the appropriate airspace classification.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Airspace management
Date, status, type
Date: 25 Mar 2022
Status: Open – Safety action pending
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2018-053-SI-03Lido airport operational information
Number: AO-2018-053-SI-03
Description: AO-2018-053-SI-03:The Lido airport operational information did not include the Australian Aeronautical Information Publication (AIP) advice to fit pitot probe covers at Brisbane Airport (related to significant mud wasp activity), as well as other safety AIP information.
Issue owner: Lufthansa Systems
Operation affected: Aviation: Other
Date, status, type
Date: 16 Mar 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-053-SI-05Change and risk management processes
Number: AO-2018-053-SI-05
Description: AO-2018-053-SI-05:Malaysia Airlines’ processes for the management of change did not follow recommended industry practices, and its risk and change management processes were not detailed and clear enough to assure: the appropriate level of involvement of subject matter expertise and safety groups that risk controls were implemented and monitored.
Issue owner: Malaysia Airlines
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Mar 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-053-SI-14Guidance about the use of pitot covers
Number: AO-2018-053-SI-14
Description: AO-2018-053-SI-14:Malaysia Airlines did not develop and disseminate guidance and procedures about the use of pitot probe covers to flight crews and engineers, and there was limited awareness among those groups of the need for pitot probe covers at Brisbane Airport.
Issue owner: Malaysia Airlines
Operation affected: Aviation: Maintenance
Date, status, type
Date: 16 Mar 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-053-SI-02Interim engineering arrangements
Number: AO-2018-053-SI-02
Description: AO-2018-053-SI-02:Malaysia Airlines did not clearly specify the division of engineering responsibilities between Malaysia Airlines and Aircraft Maintenance Services Australia engineers at Brisbane, leading to ambiguity with regard to who should conduct the final walk-around portion of the transit check. This risk was increased by the operator commencing and continuing flights ...
Issue owner: Malaysia Airlines
Operation affected: Aviation: Maintenance
Date, status, type
Date: 16 Mar 2022
Status: Closed – Adequately addressed
Type: Proactive action
First page Page 1 of 50 Last page Total records: 995