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Safety issues and actions

Issue, description, who it affects

Date, status, type

Issue, description, who it affects
Issue:	AO-2014-053-SI-05 Classification of parachuting operations
Number:	AO-2014-053-SI-05
Description:	AO-2014-053-SI-05 :Classification of parachuting operations in the private category did not provide comparable risk controls to other similar aviation activities that involve the carriage of the general public for payment.
Who it affects:	Australian parachuting industry
Issue owner:	Civil Aviation Safety Authority
Operation affected:	Aviation: General aviation

Date, status, type
Date:	23 Jun 2017
Status:	Safety action pending
Type:	Proactive Action
	Proactive Action
	Recommendation

Issue, description, who it affects
Issue:	AO-2014-053-SI-04 Restraint use in parachuting aircraft
Number:	AO-2014-053-SI-04
Description:	AO-2014-053-SI-04 :It was likely that the parachutists on the accident flight, as well as those that had participated in previous flights, were not secured to the single-point restraints that were fitted to VH-FRT. While research indicates that single-point restraints provide limited protection when compared to dual-point restraints, they do reduce the ...
Who it affects:	Australian parachuting industry
Issue owner:	Occurrence operator
Operation affected:	Aviation: General aviation

Date, status, type
Date:	23 Jun 2017
Status:	No longer relevant
Type:	Proactive Action
	Proactive Action
	Proactive Action

Issue, description, who it affects
Issue:	AO-2014-053-SI-03Dual-point restraints
Number:	AO-2014-053-SI-03
Description:	AO-2014-053-SI-03:Research has identified that rear‑facing occupants of parachuting aircraft have a higher chance of survival when secured by dual-point restraints, rather than the standard single-point restraints that were generally fitted to Australian parachuting aircraft.
Who it affects:	Australian parachuting industry
Issue owner:	Civil Aviation Safety Authority
Operation affected:	Aviation: General aviation

Date, status, type
Date:	23 Jun 2017
Status:	Safety action pending
Type:	Proactive Action
	Recommendation
	Proactive Action
	Recommendation

Issue, description, who it affects
Issue:	AO-2014-053-SI-02Unapproved aircraft flight control modifications
Number:	AO-2014-053-SI-02
Description:	AO-2014-053-SI-02:Some Cessna 206 parachuting aircraft, including VH-FRT, had their flight control systems modified without an appropriate maintenance procedure or approval. That increased the risk of flight control obstruction.
Who it affects:	Parachute jump operators
Issue owner:	Civil Aviation Safety Authority
Operation affected:	Aviation: General aviation

Date, status, type
Date:	23 Jun 2017
Status:	Adequately addressed
Type:	Proactive Action

Issue, description, who it affects
Issue:	AO-2014-053-SI-01 Secondary seat stop modification not mandatory
Number:	AO-2014-053-SI-01
Description:	AO-2014-053-SI-01 :Despite being categorised as mandatory for the pilot’s seat by the aircraft manufacturer, a secondary seat stop modification designed to prevent uncommanded rearward pilot seat movement and potential loss of control was not fitted to VH-FRT, nor was it required to be under United States or Australian regulations.
Who it affects:	Single engine Cessna aircraft operators
Issue owner:	Civil Aviation Safety Authority
Operation affected:	Aviation: General aviation

Date, status, type
Date:	23 Jun 2017
Status:	Safety action pending
Type:	Recommendation

Issue, description, who it affects
Issue:	AO-2016-003-SI-01 Air traffic facilities at Ballina/Byron Gateway Airport
Number:	AO-2016-003-SI-01
Description:	AO-2016-003-SI-01 :Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence ...
Who it affects:	All aircraft operations that utilise Ballina/Byron Gateway Airport
Issue owner:	Operator-Ballina/Byron Gateway Airport
Operation affected:	Aviation: Air transport

Date, status, type
Date:	19 May 2017
Status:	Adequately addressed
Type:	Proactive Action

Issue, description, who it affects
Issue:	AO-2014-032-SI-02Consideration of transient elevator deflections from a pitch disconnect
Number:	AO-2014-032-SI-02
Description:	AO-2014-032-SI-02:The aircraft manufacturer did not account for the transient elevator deflections that occur as a result of the system flexibility and control column input during a pitch disconnect event at all speeds within the flight envelope. As such, there is no assurance that the aircraft has sufficient strength to withstand ...
Who it affects:	All operators of ATR 42 and ATR 72 aircraft
Issue owner:	ATR
Operation affected:	Aviation: Air transport

Date, status, type
Date:	05 May 2017
Status:	Safety action pending
Type:	Recommendation
	Recommendation
	Recommendation
	Proactive Action

Issue, description, who it affects
Issue:	AO-2017-032-SI-01GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Number:	AO-2017-032-SI-01
Description:	AO-2017-032-SI-01:The ATSB advises that those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3 should note the facts presented in this preliminary report with a view to addressing any risks ...
Who it affects:	Those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Issue owner:	Operators and maintainers of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Operation affected:	Aviation: Air transport

Date, status, type
Date:	13 Apr 2017
Status:	Safety action pending
Type:	Safety Advisory Notice
	Proactive Action

Issue, description, who it affects
Issue:	AO-2013-120-SI-01Emergency oxygen mask and smoke goggles training
Number:	AO-2013-120-SI-01
Description:	AO-2013-120-SI-01:At the time of the occurrence, the approved QantasLink training did not provide first officers with sufficient familiarity on the use of the oxygen mask and smoke goggles. This likely contributed to the crew's communication difficulties, including with air traffic control.
Who it affects:	All QantasLink DHC-8-315 pilots
Issue owner:	QantasLink
Operation affected:	Aviation: Air transport

Date, status, type
Date:	07 Apr 2017
Status:	Adequately addressed
Type:	Proactive Action

Issue, description, who it affects
Issue:	AO-2016-005-SI-01Absence of air traffic control procedures and tools for runway changes at Melbourne Airport
Number:	AO-2016-005-SI-01
Description:	AO-2016-005-SI-01:Airservices Australia did not provide procedures with associated local instructions to Melbourne air traffic controllers regarding how to coordinate runway changes at Melbourne Airport. Furthermore, an absence of system tools increased the risk of the controllers forgetting to coordinate those changes with the Essendon Aerodrome Controller.
Who it affects:	Air traffic controllers at Melbourne and Essendon Airports
Issue owner:	Airservices Australia
Operation affected:	Aviation: Airspace management

Date, status, type
Date:	09 Mar 2017
Status:	Adequately addressed
Type:	Proactive Action

Issue, description, who it affects
Issue:	AO-2014-096 -SI-01Compromised separation recovery training
Number:	AO-2014-096 -SI-01
Description:	AO-2014-096 -SI-01:Compromised separation recovery training deficiencies existed within the Department of Defence at the time of the occurrence, increasing the risk of inappropriate management of aircraft in close proximity. Note: This safety issue was identified as part of ATSB investigation AO-2012-131 as safety issue AO-2012-131-SI-05 and resulted in the ATSB issuing safety recommendation AO‑2012‑131‑SR‑042 on 2 October 2014 (after the ...
Who it affects:	All Department of Defence air traffic controllers
Issue owner:	Department of Defence
Operation affected:	Aviation: Airspace management

Date, status, type
Date:	05 Dec 2016
Status:	Adequately addressed

Issue, description, who it affects
Issue:	AO-2014-164-SI-01Potential adverse effects of a tip-up canopy opening in-flight
Number:	AO-2014-164-SI-01
Description:	AO-2014-164-SI-01:In‑flight opening of the tip-up canopy in a number of Van’s Aircraft Inc. models has resulted in varying consequences, including a significant pitch down tendency, increasing the risk of a loss of control.
Who it affects:	Owners of Van’s aircraft fitted with a tip-up canopy
Issue owner:	Van’s Aircraft Inc.
Operation affected:	Aviation: General aviation

Date, status, type
Date:	25 Nov 2016
Status:	Adequately addressed
Type:	Proactive Action
	Safety Advisory Notice

Issue, description, who it affects
Issue:	AO-2016-028-SI-01Coordination of activities related to pushback
Number:	AO-2016-028-SI-01
Description:	AO-2016-028-SI-01:The procedures provided to ground and flight crews by Malaysia Airlines Berhad and the towbarless tractor operator did not provide clear guidance or instruction on coordinating activities related to pushback and, in the case of the tractor operator, were informally replaced by local procedures
Who it affects:	Air transport ground handling
Issue owner:	Malaysia Airlines Berhad and Menzies Aviation
Operation affected:	Aviation: Air transport

Date, status, type
Date:	13 Sep 2016
Status:	Adequately addressed
Type:	Proactive Action
	Proactive Action
	Safety Advisory Notice

Issue, description, who it affects
Issue:	AO-2015-114-SI-01No cockpit annunciation or checklist item for parking brake status
Number:	AO-2015-114-SI-01
Description:	AO-2015-114-SI-01:The Citation aircraft did not have an annunciator light to show that the parking brake is engaged, and the manufacturer’s before take-off checklist did not include a check to ensure the parking brake is disengaged.
Who it affects:	All owners and operators of Cessna Citation aircraft
Issue owner:	Textron Aviation (Cessna)
Operation affected:	Aviation: General aviation

Date, status, type
Date:	25 Jul 2016
Status:	Safety action pending
Type:	Proactive Action
	Recommendation

Issue, description, who it affects
Issue:	AO-2014-032-SI-01Inadvertent activation of the elevator control system - pitch uncoupling mechanism
Number:	AO-2014-032-SI-01
Description:	AO-2014-032-SI-01:Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
Who it affects:	All operators of ATR 42 and ATR 72 aircraft
Issue owner:	ATR
Operation affected:	Aviation: Air transport

Date, status, type
Date:	15 Jun 2016
Status:
Type:	Proactive Action
	Proactive Action
	Proactive Action

Issue, description, who it affects
Issue:	AO-2013-100-SI-02Alerting function of special weather reports (SPECI) is not met by the automatic broadcast services
Number:	AO-2013-100-SI-02
Description:	AO-2013-100-SI-02:The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.
Who it affects:	All pilots operating into non-major airports accessing an automatic broadcast service
Issue owner:	Airservices Australia in consultation with the Bureau of Meteorology
Operation affected:	Aviation: Air transport

Date, status, type
Date:	31 May 2016
Status:	Not addressed
Type:	Proactive Action
	Recommendation

Issue, description, who it affects
Issue:	AO-2013-100-SI-01Limited provision of flight information service for some non major airports
Number:	AO-2013-100-SI-01
Description:	AO-2013-100-SI-01:For many non‑major airports in Australia, flight crews of arriving aircraft can access current weather information using an Automatic Weather Information Service via very high frequency radio, which has range limitations. Where this service is available, air traffic services will generally not alert pilots to significant deteriorations in current weather ...
Who it affects:	All pilots operating into non-major airports accessing an Automatic Weather Information Service
Issue owner:	Airservices Australia in consultation with the Bureau of Meteorology
Operation affected:	Aviation: Air transport

Date, status, type
Date:	31 May 2016
Status:
Type:	Proactive Action

Issue, description, who it affects
Issue:	AO-2014-074-SI-02Compromised separation recovery training
Number:	AO-2014-074-SI-02
Description:	AO-2014-074-SI-02:Airservices Australia had not provided en route air traffic controllers with effective simulator-based refresher training in identifying and responding to compromised separation scenarios, at intervals appropriate to ensure that controllers maintained effective practical skills.
Who it affects:	All Airservices Australia en route air traffic controllers
Issue owner:	Airservices Australia
Operation affected:	Aviation: Airspace management

Date, status, type
Date:	13 May 2016
Status:	Adequately addressed
Type:	Proactive Action

Issue, description, who it affects
Issue:	AO-2014-074-SI-01Air traffic control shift management practices
Number:	AO-2014-074-SI-01
Description:	AO-2014-074-SI-01:The utilisation of shift sharing practices for the Tops controllers resulted in them sustaining a higher workload over extended periods without a break, during a time of day known to reduce performance capability.
Who it affects:	All Airservices Australia air traffic controllers operating on night shifts
Issue owner:	Airservices Australia
Operation affected:	Aviation: Airspace management

Date, status, type
Date:	13 May 2016
Status:	Safety action pending
Type:	Proactive Action

Issue, description, who it affects
Issue:	AO-2013-212-SI-01Identification of pitot probe in the trouble shooting manual
Number:	AO-2013-212-SI-01
Description:	AO-2013-212-SI-01:The relevant tasks in the trouble shooting manual did not specifically identify the pitot probe as a potential source of airspeed indication failure.
Who it affects:	Maintenance engineers
Issue owner:	Airbus
Operation affected:	Aviation: Air transport