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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: MO-2017-009-SI-02Vessel survey and certification
Number: MO-2017-009-SI-02
Description: MO-2017-009-SI-02:Most Australian Border Force cutters, including ABFC Roebuck Bay, were installed with ECDIS operating on non-type-approved naval software. Subsequently, DNV GL, acting on behalf of the Australian Maritime Safety Authority, incorrectly certified these vessels as using type-approved ECDIS to meet the chart carriage requirements of the regulations. This removed an ...
Who it affects: Australian flagged vessels
Issue owner: Australian Maritime Safety Authority
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 27 Jun 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2017-009-SI-01ECDIS familiarisation
Number: MO-2017-009-SI-01
Description: MO-2017-009-SI-01:Although the online VisionMaster FT ECDIS type-specific familiarisation training included the relevant content, the training as undertaken by Australian Border Force deck officers was not effective in preparing ABFC Roebuck Bay's officers for the operational use of the ECDIS.
Who it affects: Australian Border Force deck officers
Issue owner: Australian Border Force
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 27 Jun 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2017-007-SI-01 QR’s track monitoring and inspection processes
Number: RO-2017-007-SI-01
Description: RO-2017-007-SI-01 :Queensland Rail’s track monitoring and inspection processes were not effective in identifying significant deterioration in the condition of level crossing ID 2309 and its approach roads to ensure the safe operating limits of the level crossing throughout its lifecycle.
Who it affects: Rail Infrastructure Managers, Rail Operators and Road Authorities/Managers
Issue owner: Queensland Rail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 25 Jun 2019
Status: Adequately addressed
Type: Proactive Action
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: Safety action pending
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: Adequately addressed
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: Is incipient spin training permitted in your aircraft?
Description: Operating an aircraft within the stated limitations is essential to the safe conduct of a flight. Training organisations are required to conduct incipient spin recovery training, which includes intentionally inducing a spin and recovering before it fully develops. Some organisations may be conducting this training in aircraft not approved for ...
Who it affects: Flight training organisations
Issue owner:
Operation affected:
Date, status, type
Date: 22 May 2019
Original risk: Significant
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2016-009-SI-05Inaccuracies in ALCAM survey data
Number: RO-2016-009-SI-05
Description: RO-2016-009-SI-05:Errors remained within the ALCAM database due to the type of equipment used to measure road and rail bearings during ALCAM surveys in 2009.  
Who it affects: All owners and operators of rail transport services in Victoria
Issue owner: VicTrack
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 21 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-009-SI-04Risk assessment and deployment of available risk controls
Number: RO-2016-009-SI-04
Description: RO-2016-009-SI-04:V/Line’s level crossing assessment processes did not result in deployment of available risk controls at many passively protected acute-angle level crossings.
Who it affects: V/Line Pty Ltd
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 21 May 2019
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-009-SI-03Risks at other acute-angle level crossings on network
Number: RO-2016-009-SI-03
Description: RO-2016-009-SI-03:More than 100 level crossings in the V/Line regional rail network (including 35 at the intersection of passenger lines and public roads) were non-compliant with the left-side viewing angle requirements of AS 1742.7:2016. These crossings had an acute road-to-rail angle that affected the ability of drivers to sight trains approaching ...
Who it affects: V/Line Pty Ltd
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 21 May 2019
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-009-SI-02V/Line and Colac Otway Shire Council interaction
Number: RO-2016-009-SI-02
Description: RO-2016-009-SI-02:The interaction between V/Line and the Colac Otway Shire Council was ineffective at addressing identified sighting issues at the Phalps Road level crossing.
Who it affects: V/Line Pty Ltd
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 21 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-009-SI-01Risk controls at Phalps Road level crossing
Number: RO-2016-009-SI-01
Description: RO-2016-009-SI-01:Available risk controls to manage the risk posed by known sighting deficiencies at the Phalps Road level crossing were not deployed by V/Line or the Colac Otway Shire Council.
Who it affects: V/Line Pty Ltd
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 21 May 2019
Status: Adequately addressed
Type: Proactive Action
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
First page Page 2 of 88 Last page Total records: 1759