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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2013-187-SI-02Removal of wings to complete service bulletin actions
Number: AO-2013-187-SI-02
Description: AO-2013-187-SI-02:Although wing removal was necessary to provide adequate access for effective visual and magnetic particle inspections of M18 wing attachment fittings, the aircraft manufacturer’s service bulletin E/02.170/2000 allowed the wings to remain attached during these inspections.
Who it affects: Maintainers of M18 aircraft completing CASA AD/PZL/5 and PZL Mielec service bulletin E/02.170/2000
Issue owner: PZL Mielec
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-04Spectrum of flight loads
Number: AO-2013-187-SI-04
Description: AO-2013-187-SI-04:Operation of M18 aircraft with a more severe flight load spectrum results in greater fatigue damage than anticipated by the manufacturer when determining the service life of the M18. If not properly accounted for, the existing service life limit, and particular inspection intervals, may not provide the intended level of ...
Who it affects: All operators of M18 aircraft
Issue owner: Operators of M18 aircraft
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-03Use of eddy current inspection for airworthiness directive AD/PZL/5
Number: AO-2013-187-SI-03
Description: AO-2013-187-SI-03:The eddy current inspection used on VH-TZJ, and other M18 aircraft, had not been approved by the Civil Aviation Safety Authority as an alternate means of compliance to airworthiness directive AD/PZL/5. This exposed those aircraft to an inspection method that was potentially ineffective at detecting cracks in the wing attachment ...
Who it affects: All operators of M18 aircraft that have had their M18s inspected using the eddy current procedure QP.00.36 (EC)
Issue owner: Aviation NDT Services Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-06Adequacy of the eddy current inspection procedure
Number: AO-2013-187-SI-06
Description: AO-2013-187-SI-06:The documented procedure for eddy current inspection of M18 wing attachment fittings did not assure repeatable, reliable inspections.
Who it affects: All operators of M18 aircraft that have had their M18s inspected using eddy current procedure QP.00.36 (EC)
Issue owner: Aviation NDT Services Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-187-SI-07Civil Aviation Safety Authority records
Number: AO-2013-187-SI-07
Description: AO-2013-187-SI-07:Important information relating to Civil Aviation Safety Authority (CASA) airworthiness directive AD/PZL/5 was not contained in CASA’s airworthiness directive file, but on other CASA files with no cross-referencing between those files. This impacted CASA’s future ability to reliably discover that information and make appropriately‑informed decisions regarding the airworthiness directive.
Who it affects: All aircraft operators in Australia
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-08Assessment of NDT procedures
Number: AO-2013-187-SI-08
Description: AO-2013-187-SI-08:The Civil Aviation Safety Authority did not have a defined process for a robust, systematic approach to the assessment and approval of alternative non-destructive inspection procedures to ensure that the proposed method provided an equivalent, or better, level of safety than the original procedure.
Who it affects: All aircraft operators in Australia
Issue owner: Civil Aviation Safety Authority records
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-09Australian supplemental type certificate SVA521
Number: AO-2013-187-SI-09
Description: AO-2013-187-SI-09:The engineering justification supporting Australian supplemental type certificate SVA521 did not contain consideration of the effect an increase in the average operating speed could have on the rate of fatigue damage accumulation.
Who it affects: All aircraft operators of the M18 aircraft in Australia operating under STC SVA521
Issue owner: Rebel Ag Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-114-SI-01Flying school spin recovery training
Number: AO-2014-114-SI-01
Description: AO-2014-114-SI-01:The spin recovery methods taught by the flying school were inconsistent across instructors and training material, and were not always appropriate for the Chipmunk aircraft type used by the school.
Who it affects: Instructors and student pilots undertaking aerobatic and spin recovery instruction
Issue owner: Airborne Aviation Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 04 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-226-SI-04Unknown fatigue life of alternative tie rod design
Number: AO-2013-226-SI-04
Description: AO-2013-226-SI-04:When approving the change in material for the manufacture of the replacement tie rods, the design engineer did not identify that the original parts had a life limitation, or that they had shown susceptibility to fatigue cracking. As a result, the engineer did not compare the fatigue performance of the ...
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-226-SI-06Fuselage lateral tie rod Australian Parts Manufacturer Approval
Number: AO-2013-226-SI-06
Description: AO-2013-226-SI-06:It was likely that, because of the Civil Aviation Safety Authority’s policy at the time, their engineering assessment of the tie rod design for inclusion in the manufacturer’s Australian Parts Manufacturer Approval did not consider the service history of the original tie rods or identify that they were subject to ...
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-226-SI-05Australian Parts Manufacturer Approval tie rods not identified by part and serial number
Number: AO-2013-226-SI-05
Description: AO-2013-226-SI-05:The JRA-776-1 fuselage lateral tie rods that were inspected by the ATSB were not appropriately marked with part and serial numbers, affecting the traceability and service history of the parts in a number of aircraft. 
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Issue owner: J & R Aerospace
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-226-SI-02Australian Parts Manufacturer Approval manufacturer’s quality system
Number: AO-2013-226-SI-02
Description: AO-2013-226-SI-02:The manufacturer’s quality system did not prevent non-conforming tie rods from being released for use on aircraft. 
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Issue owner: J & R Aerospace
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-226-SI-03Non-standard Joint H fitting upper attachment hardware
Number: AO-2013-226-SI-03
Description: AO-2013-226-SI-03:Together with a number of other Australian Tiger Moths, VH-TSG was fitted with non‑standard Joint H attachment bolts that did not conform to the original design with the result that the integrity of the Joint H could not be assured.
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft
Issue owner: Civil Aviation Safety Authority and de Havilland Support Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-226-SI-07Civil Aviation Safety Authority Australian Parts Manufacturer Approval implementation approvals
Number: AO-2013-226-SI-07
Description: AO-2013-226-SI-07:Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life‑limits, were appropriately considered.
Who it affects: Operators of aircraft fitted with parts manufactured under those Australian Parts Manufacturer Approvals
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Airspace management
Date, status, type
Date: 21 Jan 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2013-226-SI-08Commercial Tiger Moth joy flight operations with high aerobatic utilisation
Number: AO-2013-226-SI-08
Description: AO-2013-226-SI-08:Although a number of aerobatic manoeuvres were permitted in Tiger Moth aircraft, there was no limitation on the amount of aerobatic operations that was considered to be safe. As a result, operators may be unaware that a high aerobatic usage may exceed the original design assumptions for the aircraft. 
Who it affects: Commercial Tiger Moth joy flight operators
Issue owner: de Havilland Support Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-010-SI-01Unique indications for E Frame on Network control system screens
Number: RO-2015-010-SI-01
Description: RO-2015-010-SI-01:The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 05 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-172-SI-01Uncontained failure of air turbine starter led to loss of engine oil
Number: AO-2013-172-SI-01
Description: AO-2013-172-SI-01:Debris originating from the starter failure was not contained by the starter casing and severed the number one engine B-sump oil scavenge pipe. 
Who it affects: All operators of engines fitted with Honeywell ATS200-61 model starters
Issue owner: Honeywell / General Electric
Operation affected: Aviation: Air transport
Date, status, type
Date: 10 Dec 2015
Status: Adequately addressed
Type: Proactive Action
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Issue, description, who it affects
Issue: AO-2014-162-SI-01Flight crew operating manual procedure for Vref40 check
Number: AO-2014-162-SI-01
Description: AO-2014-162-SI-01:The Flight Crew Operating Manual procedure for crew comparison of the calculated Vref40 speed, while designed to assist in identifying a data entry error, could be misinterpreted, thereby negating the effectiveness of the check.
Who it affects: All Qantas Boeing 737 pilots
Issue owner: Qantas Airways Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Nov 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-160-SI-01Absence of prior planning
Number: AO-2013-160-SI-01
Description: AO-2013-160-SI-01:The applicability of a general requirement to conduct aviation risk assessments for complex, new, unusual or irregular activities was open to interpretation.
Who it affects: Department of Defence air traffic services
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 12 Nov 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-120-SI-01Assigning approaches to foreign operators
Number: AO-2012-120-SI-01
Description: AO-2012-120-SI-01:Unlike other Australian standard arrival routes that included a visual segment, the visual approach to runway 34 at Melbourne via the SHEED waypoint could be issued to super or heavy jet aircraft operated by foreign operators, despite there being more occurrences involving the SHEED waypoint than other comparable approaches.
Who it affects: All foreign operators of super or heavy jet aircraft conducting a visual approach to runway 34 at Melbourne via the SHEED waypoint
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 01 Sep 2015
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
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