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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: RO-2017-016-SI-01Track defect management
Number: RO-2017-016-SI-01
Description: RO-2017-016-SI-01:ARTC allowed identified track twist defects to remain in track contrary to network track geometry requirements.
Who it affects: Track Managers
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Freight
Date, status, type
Date: 06 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2018-002-SI-01Train driver maintenance of competency assurance
Number: RO-2018-002-SI-01
Description: RO-2018-002-SI-01:Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements.
Who it affects: Queensland Rail Citytrain rail traffic drivers
Issue owner: Queensland Rail
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Feb 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2017-001-SI-01Inadequate on-board documentation
Number: MO-2017-001-SI-01
Description: MO-2017-001-SI-01:Guidelines for the provision, care and use of shipboard equipment were not supported by suitable documentation. The only documentation was for mobile scaffolding equipment of different design and not for that in use on the ship.
Who it affects: All owners and operators and crewmembers involved in working aloft
Issue owner: Asia Maritime Pacific
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 21 Feb 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-007-SI-04Audit response
Number: MO-2015-007-SI-04
Description: MO-2015-007-SI-04:The regional harbour master and the pilotage service did not have processes in place to follow up audit findings, to ensure that they were appropriately monitored, actioned and closed out in a timely manner.
Who it affects: All ships entering and departing Townsville under pilotage
Issue owner: Maritime Safety Queensland
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 Feb 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-007-SI-03Tug reduction process
Number: MO-2015-007-SI-03
Description: MO-2015-007-SI-03:The Port Procedures manual for Townsville allowed shipping agents to request a tug reduction without the knowledge of the ship’s master.
Who it affects: All ships entering and departing Townsville under pilotage
Issue owner: Maritime Safety Queensland and Port of Townsville Limited Pilotage Services
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 Feb 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-007-SI-02Contingency planning
Number: MO-2015-007-SI-02
Description: MO-2015-007-SI-02:The Port of Townsville Limited Pilotage Services’ Pilotage Service Safety Management System did not have documented guidance on berthing manoeuvres nor any associated contingencies.
Who it affects: All ships entering and departing Townsville under pilotage
Issue owner: Port of Townsville Limited Pilotage Services
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 Feb 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-007-SI-01Risk management
Number: MO-2015-007-SI-01
Description: MO-2015-007-SI-01:The Port of Townsville Limited Pilotage Service risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks during pilotage.
Who it affects: All ships entering and departing Townsville under pilotage
Issue owner: Port of Townsville Limited Pilotage Services
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 Feb 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AR-2017-011-SI-01 Wake turbulence occurrences at Sydney Airport
Number: AR-2017-011-SI-01
Description: AR-2017-011-SI-01 :Given the parallel runway configuration, there was a disproportionate rate of reported wake turbulence occurrences for aircraft arriving at Sydney Airport compared to other major Australian airports in the years 2012 to 2016. Wake turbulence occurrences at Sydney Airport were found to be primarily associated with three factors: arrival densities of ...
Who it affects: Aircraft arriving at Sydney Airport
Issue owner: Airservices Australia
Operation affected: Aviation: Air transport
Date, status, type
Date: 15 Feb 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2017-001-SI-01Loading of train
Number: RO-2017-001-SI-01
Description: RO-2017-001-SI-01:The train was loaded by approximately 10 per cent more than that recorded on the consist, it is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train.
Who it affects: All owners and operators of freight wagons
Issue owner: Qube Logistics
Operation affected: Rail: Freight
Date, status, type
Date: 05 Dec 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-160-SI-01Policies and procedures for planning IFR and NVIS flights
Number: AO-2016-160-SI-01
Description: AO-2016-160-SI-01:Although the operator’s operations manual stated that emergency medical service flights should be conducted under instrument flight rules (IFR) ‘where practical’, its procedures for night visual flight rules (NVFR) operations using night vision goggles did not clearly state when IFR rather than NVFR should be used.  
Who it affects: Operating crew and other occupants on emergency medical service flights
Issue owner: CHC Helicopter Australia
Operation affected: Aviation: Air transport
Date, status, type
Date: 06 Nov 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2018-016-SI-02 Balloon passenger briefing procedures
Number: AO-2018-016-SI-02
Description: AO-2018-016-SI-02 :Although the operator had procedures for conducting a verbal safety briefing prior to flight and had safety briefing cards available, its risk controls did not provide assurance that all passengers would understand the required procedures for emergency landings. More specifically: safety briefing cards were not routinely made available to passengers prior ...
Who it affects: Crew and passengers on the operator’s flights
Issue owner: Go Wild Ballooning Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 30 Oct 2018
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2018-016-SI-01 Procedures for uploading balloon forecasts
Number: AO-2018-016-SI-01
Description: AO-2018-016-SI-01 :The Bureau of Meteorology did not have a procedure to ensure that a recording of the local weather forecast for balloon operations in the Melbourne area was correctly uploaded and accessible to balloon pilots.
Who it affects: All balloon operators and pilots in the Melbourne region
Issue owner: Bureau of Meteorology
Operation affected: Aviation: General aviation
Date, status, type
Date: 30 Oct 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-023-SI-01 Rail condition
Number: RO-2015-023-SI-01
Description: RO-2015-023-SI-01 :The general condition of the rail on the west track, in the vicinity of the rail fracture, contributed to relatively frequent failures in that area.
Who it affects: Users of the affected rail track
Issue owner: BHP Billiton
Operation affected: Rail: Freight
Date, status, type
Date: 12 Oct 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2017-032-SI-01 Lack of inspection method to detect fracture
Number: AO-2017-032-SI-01
Description: AO-2017-032-SI-01 :The engine manufacturer did not have specific inspection procedures in the maintenance documents of the propeller shaft to detect a fatigue crack originating from the dowel pin hole.
Who it affects: All owners and operators of GE CT7-5A2/-5A3/-9B/-9B2 series engines
Issue owner: General Electric (GE)
Operation affected: Aviation: Air transport
Date, status, type
Date: 10 Oct 2018
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2015-046-SI-05In-flight landing distance safety margin may be inadequate
Number: AO-2015-046-SI-05
Description: AO-2015-046-SI-05:Civil Aviation Order 20.7.1B stipulated that a 1.15 (15 per cent) safety margin was to be applied to the actual landing distance for jet-engine aircraft with a maximum take-off weight greater than 5,700 kg. This safety margin may be inadequate under certain runway conditions, which increases the risk of a ...
Who it affects: Civil Aviation Safety Authority
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Sep 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-046-SI-03Cross-checking environmental information and landing performance
Number: AO-2015-046-SI-03
Description: AO-2015-046-SI-03:Virgin Australia Airlines/Virgin Australia International did not have a policy requiring crews to independently cross-check environmental information and landing performance calculations in-flight, removing an opportunity to detect crew errors.
Who it affects: Virgin Australia Airlines/Virgin Australia International crews
Issue owner: Virgin Australia Airlines/Virgin Australia International
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Sep 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-046-SI-02Regulatory direction regarding damp runways
Number: AO-2015-046-SI-02
Description: AO-2015-046-SI-02:There was no regulatory direction from the Civil Aviation Safety Authority on how a damp runway was to be considered for aircraft landing performance.
Who it affects: Operators and pilots of aircraft where landing performance data is not available for damp runway surface conditions
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Sep 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-046-SI-01Change in ‘damp’ definition for performance purposes
Number: AO-2015-046-SI-01
Description: AO-2015-046-SI-01:Several months prior to the incident, Virgin Australia Airlines/Virgin Australia International changed their policy on calculating landing performance for damp runways from referencing a wet runway to a dry runway.
Who it affects: Virgin Australia Airlines/Virgin Australia International crews
Issue owner: Virgin Australia Airlines/Virgin Australia International
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Sep 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-084-SI-01Hazard associated with the inability to separate aircraft below the appropriate lowest safe altitude at night
Number: AO-2015-084-SI-01
Description: AO-2015-084-SI-01:The hazard associated with the inability to separate aircraft that are below the appropriate lowest safe altitude at night was identified but not adequately mitigated. This resulted in a situation where, in the event of a simultaneous go-around at night during land and hold short operations at Melbourne Airport, there ...
Who it affects: Air traffic controllers employed in the Melbourne Tower
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 06 Aug 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-078-SI-01Air Operator Certificate holder fuel policy requirements
Number: AO-2016-078-SI-01
Description: AO-2016-078-SI-01:The current legislation does not require commercial operators of aircraft not greater than 5,700 kg maximum take-off weight to provide instructions and procedures for crosschecking the quantity of fuel on board before and/or during flight. This increases the risk that operators in this category will not implement effective fuel policies ...
Who it affects: Air Operator Certificate holders
Issue owner: Civil Aviation Safety Authority (CASA)
Operation affected: Aviation: Air transport
Date, status, type
Date: 02 Aug 2018
Status: Adequately addressed
Type: Proactive Action
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First page Page 1 of 86 Last page Total records: 1706