section-5
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Formal safety issues and actions

ATSB investigations primarily improve transport safety by identifying and addressing safety issues. Safety issues are events or conditions that increase safety risk and:

  • can reasonably be regarded as having the potential to adversely affect the safety of future operations, and
  • are characteristics of an organisation or a system, rather than of a specific individual, or operational environment at a specific point in time.

Safety issues will usually refer to an organisation’s risk controls, or to a variety of internal and external organisational influences that impact the effectiveness of its risk controls. They are factors for which an organisation has some level of control and responsibility and, if not addressed, will increase the risk of future accidents.

The ATSB prefers to encourage stakeholders to take proactive safety action to address safety issues identified in its reports. Nevertheless, the ATSB may use its powers under the Transport Safety Investigation Act 2003 (TSI Act) to make a formal safety recommendation either during or at the end of an investigation—depending on the level of risk associated with a safety issue and the extent of corrective action already taken.

When safety recommendations are issued, they clearly describe the safety issue of concern—they do not provide instructions or opinions on a preferred corrective action. Like equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the organisation to which an ATSB recommendation is directed to assess the costs and benefits of any means of addressing a safety issue and act appropriately.

When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation.

The ATSB can also issue a safety advisory notice (SAN) suggesting that an organisation, or an industry sector, consider a safety issue and take appropriate action. There is no requirement for a formal response to a SAN.

Safety issues are broadly classified in terms of their level of risk:

  • critical safety issue—associated with an intolerable level of risk and generally leading to the immediate issue of a safety recommendation unless corrective safety action has already been taken
  • other safety issue—associated with a risk level regarded as unacceptable unless it is kept as low as reasonably practicable. Where there is a reasonable expectation that safety action could be taken in response to reduce risk, the ATSB will issue a safety recommendation to the appropriate agency when proactive safety action is not forthcoming.

All ATSB safety issues and associated safety actions, along with the most recent status, are published on the ATSB website for all investigation reports released since July 2010.

Safety issues identified through ATSB investigations

All safety issues are risk assessed by the ATSB. In 2016–17, the ATSB identified the following number of safety issues.

Table 7: Number of safety issues identified in 2016–17

Safety issue risk

Aviation

Marine

Rail

Total

Critical

1

0

0

1

Other

12

10

11

33

Total

13

10

11

34

Safety action is sought to address any safety issues when proactive safety action is not forthcoming. Once safety action has been undertaken, the ATSB conducts another risk assessment of the safety issue. When the post-action risk assessment results in either an acceptable level of risk or a risk as low as reasonably practicable, the safety issue status is categorised as ‘adequately addressed’.

The Portfolio Budget Statements 2016–17 specify, as two of the ATSB’s key performance indicators (KPIs), that:

  • safety action is taken by stakeholders to address 100 per cent of critical safety issues identified
  • safety action is taken by stakeholders to address 70 per cent of all other safety issues identified.

KPI status of safety issues identified in 2016–17

There was one critical risk safety issue identified through ATSB investigations in 2016–17. At the time of publication, safety action was still pending.

The breakdown of other safety issues, by transport mode, is summarised in the following table:

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Table 8: Status of other safety issues identified in 2016–17

Status of safety issues

Aviation

Marine

Rail

Per cent

Adequately addressed

7

8

7

67%

Partially addressed

0

1

1

6%

Not addressed

0

0

0

0%

No longer relevant

1

0

0

3%

Safety action still pending

4

1

3

24%

Total

12

10

11

100%

Responses to safety issues identified in 2016–17

The tables below document each safety issue identified in 2016–17 and its current status assigned by the ATSB, along with the justification for that status.

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Table 9: Aviation critical safety issues identified in 2016–17

Safety issue

Status

Status justification

AO-2014-032: In-flight pitch disconnect involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, New South Wales, 20 February 2014

AO-2014-032-SI-02: The aircraft manufacturer (ATR) 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 the loads resulting from a pitch disconnect.

Safety action pending

The ATSB acknowledges the efforts of ATR with regard to the detailed engineering analysis of the transient elevator deflections. The preliminary results have shown that the system responds in an underdamped oscillatory manner, resulting in elevator deflections greater than those identified by the static analysis previously carried out by ATR. The ATSB is encouraged by the level of detail into which ATR has developed the analysis and will continue to monitor their progress. Until such time that the analysis has satisfactorily shown that the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect, the identified safety issue will remain open.

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Table 10: Aviation—Responses to other safety issues identified in 2016–17

Safety issue

Status

Status justification

AO-2013-120: Smoke event involving a Dash 8-300, VH-SBG, near Canberra Airport, Australian Capital Territory, 29 July 2013

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.

Adequately addressed

The ATSB is satisfied that the action taken by QantasLink has adequately addressed the safety issue.

AO-2014-053: Collision with terrain involving Cessna 206, VH-FRT, Caboolture Airfield, Queensland, 22 March 2014

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.

Safety action pending

The ATSB recommends that Civil Aviation Safety Authority (CASA) takes action to strengthen incorporation of Cessna Single Engine Service Bulletin SEB07-5 secondary seat stop modification.

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.

Adequately addressed

As a result of the safety action taken by CASA and the Australian Parachute Federation, aircraft operators have increased awareness of this safety issue. Consequently, the ongoing safety risk is considered acceptable.

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.

Safety action pending

The ATSB recommends that the Australian Parachute Federation, in conjunction with CASA, takes action to increase the usage of dual point restraints in parachuting aircraft that are configured for rear-facing occupants.

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 risk of load shift following an in-flight upset, which can lead to aircraft controllability issues.

No longer relevant

The safety issue owner is no longer conducting parachuting operations.

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.

Safety action pending

The ATSB recommends that CASA introduce risk controls to parachuting operations that provide increased assurance of aircraft serviceability, pilot competence and adequate regulatory oversight.

AO-2014-096: ATC information error involving a Department of Defence Boeing CH-47 Chinook and Cessna 172S, VH-PFU, Townsville Airport, Queensland, 27 May 2014

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.

Adequately addressed

The ATSB is satisfied that the action taken by the Department of Defence in response to AO-2012-131-SI-05, which was enacted after the occurrence at Townsville in 2014, also adequately addresses safety issue AO-2014-096-SI-01. Compromised separation recovery training is included in Defence air traffic controller initial and currency proficiency assessments. In addition, video and computer-based training in compromised separation recovery techniques is a pre-requisite for Defence controllers’ six-monthly currency assessments. It is also included in the simulator scenarios of Defence air traffic units at all military aerodromes to which civil scheduled services operate.

AO-2014-164: Collision with terrain involving Van’s RV-6A, VH-JON, 8 km south of Moorabbin Airport, Victoria, 14 October 2014

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.

Adequately addressed

The safety action taken by Van’s Aircraft Inc. will, once the service letter is distributed, make builders and operators of Van’s Aircraft Inc. aircraft fitted with a tip-up canopy aware of the consequences of the canopy opening in flight, and how to reduce the risk of such an event. The ATSB will monitor the release of the service letter.

AO-2015-114: Runway excursion involving Cessna 550, VH-FGK, Lismore Airport, New South Wales, 25 September 2015

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.

Safety action pending

The ATSB recommends that Textron Aviation (Cessna) take safety action to address the fact that Citation aircraft do not have an annunciator light to show that the parking brake is engaged and the Cessna ‘before take-off’ checklist does not include a check to ensure the parking brake is disengaged.

AO-2016-003: Traffic management occurrence involving Airbus A320, VH-VQS, and Beech Aircraft Corporation, VH-EWL, at Ballina/Byron Gateway Airport, New South Wales, 14 January 2016

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 of these facilities, which have been shown to provide good mitigation at other airports with similar traffic levels, increased the risk of a mid-air conflict in the Ballina area.

Adequately addressed

The ATSB is satisfied that the implementation of the CA/GRS will adequately address the potential for mid-air conflict identified in the safety issue.

AO-2016-005: Loss of separation involving Boeing 737 aircraft, VH-YFN and VH-VZV, and Robinson R44, VH-WYR, near Essendon Airport, Victoria, 26 January 2016

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.

Adequately addressed

The action by Airservices Australia minimises the risk associated with the safety issue.

AO-2016-028: Ground handling occurrence involving Airbus A330, 9M-MTB, at Melbourne Airport, Victoria, 31 March 2016

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. In the case of the tractor operator, these were informally replaced by local procedures.

Adequately addressed

The proactive safety actions taken and planned by Malaysia Airlines Berhad and Menzies Aviation, in conjunction with the additional safety action taken by Aircraft Maintenance Services Australia (the engineering organisation), will improve crew coordination during ground operations and adequately address the safety issue.

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Table 11: Marine—Responses to safety issues identified in 2016–17

Safety issue

Status

Status justification

MO-2015-002: Grounding of Maersk Garonne, Fremantle, Western Australia, 28 February 2015

MO-2015-002-SI-01: Bridge resource management (BRM) was not effectively implemented on board Maersk Garonne. The ship’s passage plan for the pilotage was inadequate, its bridge team members were not actively engaged in the pilotage and they did not effectively monitor the ship’s passage.

Adequately addressed

The issues identified and safety action taken by Maersk Line Ship Management, along with planned enhancements, indicate the company’s commitment to reiterating the roles and responsibilities of the master and crew during navigation with a pilot on board. The company’s Nautical Excellence program will enhance bridge resource management and improve compliance with bridge procedures.

MO-2015-002-SI-02: Fremantle Pilots’ publicly available information to assist ship’s masters in preparing a berth-to-berth passage plan was inadequate and ineffectively implemented. The information provided consisted essentially of a list of waypoints, which was routinely not followed.

Adequately addressed

The safety actions undertaken by Fremantle Pilots should ensure that the waypoint list made available to ship’s masters more closely matches the track that the pilot will follow. This will assist masters in more accurately preparing the required berth-to-berth passage plan.

MO-2015-002-SI-03: Fremantle Pilots’ procedures did not include any contingency plans, including abort points, for risks identified for the pilotage.

Adequately addressed

The actions taken will ensure that pilotage into Fremantle has been adequately assessed and contingency procedures and manoeuvres have been planned and practised. Changes to pilotage passage procedures will mean that the safety margins will be increased.

MO-2015-002-SI-04: Procedures for harbour tugs to meet inbound ships and for their coordinated movement in the Fremantle pilotage area were not clearly defined. On 28 February, inadequate coordination of the tugs and ineffective communication between Maersk Garonne’s pilot and the tug masters resulted in both tugs, the second one in particular, being significantly delayed from when they could reasonably have been expected to be on station.

Adequately addressed

The actions taken by Fremantle Ports, Fremantle Pilots and Svitzer Australia clarify the roles and responsibilities of all parties with respect to the monitoring and management of tugs during pilotage and port entry. This increases safety margins and reduces the likelihood of a similar incident occurring in the future.

MO-2015-005: Fatal injury on board Skandi Pacific, off the Pilbara coast, Western Australia, 14 July 2015

MO-2015-005-SI-01: Skandi Pacific’s safety management system (SMS) procedures for cargo handling in adverse weather conditions were inadequate. Weather limits outlining when cargo handling operations could be undertaken and trigger points for suspending operations were not defined, including limits for excessive water on deck.

Adequately addressed

The revised procedures for working in adverse weather conditions and cargo handling, and the additional safety action taken, has adequately addressed the safety issue.

MO-2015-005-SI-02: Skandi Pacific’s SMS procedures for cargo securing were inadequate. There was no guidance for methods of securing cargo in adverse weather conditions.

Adequately addressed

The revised procedures and risk assessments for cargo handling and securing, and the additional safety action taken, has adequately addressed the safety issue.

MO-2015-005-SI-03: Skandi Pacific’s managers had not adequately assessed the risks associated with working on the aft deck of vessels with open sterns, including consideration of engineering controls to minimise water being shipped on the aft deck.

Partially addressed

The ATSB acknowledges the proactive safety taken by DOF Management following the issue of a recommendation that DOF Management undertake further action to adequately address the safety issue concerning the use of vessels with open sterns. The further proactive safety action included: bridge familiarisations for open stern vessels; amended SMS procedures specifically related to adverse weather conditions and cargo handling; risk assessments for working stern to weather; loading/offloading at installation; and securing deck cargoes. Additionally, in late 2016, DOF joined an offshore industry working group and identified areas for consideration and improvement across their industry. The areas included cargo shift, cargo securing manuals, offshore skip bins and open stern vessels. Further, DOF Management are trialling a swing type wave barrier gate. Therefore, the ATSB will continue to monitor the safety issue/action subject to receiving notice of the result and final outcome.

MO-2016-001: Breakaway of Spirit of Tasmania II, Station Pier, Port Melbourne, Victoria, 13 January 2016

MO-2016-001-SI-01: The adverse weather procedures for TT-Line ships when alongside did not take into account all the necessary factors to provide effective defences against significant, short-term weather events, such as thunderstorms and squalls.

Adequately addressed

Enhancements to ship operating procedures should improve the ability to hold the ship alongside and provide for swifter response to changing weather conditions. In addition, improved analysis and notification of weather conditions, forecasts and warnings should allow ships’ crew to be better informed and, hence, better prepared. The review of the mooring arrangements should further inform and complement these changes.

MO-2016-001-SI-02: The Port of Melbourne vessel traffic service (VTS) procedures for adverse weather were not comprehensive and, hence, its response on 13 January was only partially effective. One important consequence was that VTS’s advance warning of storm force winds did not reach all relevant parties, including the Spirit of Tasmania II’s master.

Adequately addressed

The notice to mariners and the port information notice clarify the responsibility of ship’s masters to actively and continuously monitor weather and related vessel traffic service communications via VHF radio.

MO-2016-001-SI-03: While TT-Line Company’s standard mooring line pattern for ships at Station Pier had been successfully used for many years, the breakaway indicated the risk could have been further reduced to better prepare for such unusual circumstances.

Safety action pending

In addition to the proactive action taken to date, further action by TT-Line following the completion of its mooring analysis has the potential to adequately address the safety issue.

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Table 12: Rail—Responses to safety issues identified in 2016–17

Safety issue

Status

Status justification

RO-2014-016: Collision between V/Line train 8280 and Metro Trains Melbourne train 6502 at Altona, Victoria, 22 August 2014

RO-2014-016-SI-01: The rules pertaining to passing a permissive signal at stop place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.

Safety action pending

The ATSB is not satisfied that the proposed actions are sufficient to prevent a recurrence of this type of accident. Until further information is provided by MTM which satisfies the ATSB that the safety issue is adequately addressed, the ATSB will retain the status of this safety issue as ‘pending’.

RO-2014-016-SI-02: The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.

Safety action pending

The ATSB accepts MTM’s proposed actions on this safety recommendation. However, until the proposed actions are completed, the ATSB will retain the status of this safety issue as ‘pending’.

RO-2015-009: Signals passed at danger by train 1240 at Marshall (Geelong), Victoria, 29 May 2015

RO-2015-009-SI-01: The training and assessment of the driver did not ensure that he had an adequate understanding of the two-position signalling through Marshall.

Adequately addressed

The proactive safety action taken by V/Line should address the gap in training identified in the safety issue.

RO-2015-009-SI-02: The rule describing the required driver response to a distant signal at caution in a two-position signalling system did not fully reflect the signalling system design principles.

Adequately addressed

V/Line has amended Rule 5 Section 2 (distant signals).

RO-2015-022: Derailment of freight train 9150 at Nunga (near Ouyen), Victoria, 9 November 2015

RO-2015-022-SI-01: Asset management systems that were used to identify problematic levels of rail creep did not evaluate or assess cumulative creep.

Adequately addressed

The proactive safety action taken addresses the monitoring of future cumulative creep. The assessment of older records, together with field validations, should identify latent cumulative creep.

RO-2015-022-SI-02: There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.

Partially addressed

The proactive safety action taken provides the methodology to be used to evaluate the stress condition of rail in instances where there is evidence of creep or incorrect stress. However, there is limited enhancement in the scope of inspection, and there continues to be a high level of reliance on asset management systems to identify rail creep in jointed track. The ATSB recognises that improvements have been made in the asset management systems, as described under safety issues RO-2015-022-SI-01 and RO-2015-022-SI-04.

RO-2015-022-SI-03: The procedures for measuring, assessing and remediating rail creep in the spring did not ensure creep defects were addressed in a timely manner and prior to the onset of hot weather. A creep defect identified by the spring measurements was not corrected before the derailment.

Adequately addressed

The proactive action taken should address the safety issue.

RO-2015-022-SI-04: Asset management systems that were used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.

Adequately addressed

The proactive action taken should address the safety issue.

RO-2015-028: Derailment of Aurizon train near Julia Creek, Queensland, 27 December 2015

RO-2015-028-SI-01: The Queensland Rail (QR) General Operational Safety Manual (MD-10-107) contained insufficient guidance for rail traffic crews to ensure the timely identification and management of a potential hazard (resulting from a weather event) that might affect the safe progress of the train.

Adequately addressed

The ATSB is satisfied that the initial actions taken by QR will address this safety issue. The ATSB encourages QR to continue working towards incorporating additional guidance to improve the effectiveness of the network rules with respect to managing weather conditions.

RO-2015-028-SI-02: The Queensland Rail network rules, procedures and safety manual provided insufficient guidance to identify the magnitude of the potential hazard from a weather event, or define the response when encountering water that had previously overtopped the track and receded or was pooled against the track formation or ballast.

Adequately addressed

The ATSB is satisfied that the initial actions taken by QR will address this safety issue. The ATSB encourages QR to continue working towards incorporating additional guidance to improve the effectiveness of the network rules with respect to managing weather conditions.

RO-2016-007: Derailment of freight train 9305 at Katunga, Victoria, 30 May 2016

RO-2016-007-SI-01: The inspection regime to identify rail fractures was ineffective for the condition of this track.

Safety action pending

The ATSB accepts that the replacement of front of train inspection with hi-rail patrols will increase the opportunity to detect fractured rail. The ATSB also considers that the proposed risk review, when completed, has the potential to result in a safety action that reduces the likelihood of a derailment following a fracture. The ATSB considers that the safety issue has been partially addressed and has issued a safety recommendation.

The ATSB recommends that V/Line completes the risk review and implements safety actions to reduce the likelihood of derailment following a rail fracture.

Safety actions

Table 13: Number of safety actions released in 2016–17

Safety action type

Aviation

Marine

Rail

Total

Proactive safety action

8

11

7

26

Safety Advisory Notice

3

1

0

4

Safety recommendation

8

2

4

14

Total

19

14

11

44

ATSB recommendations closed in 2016–17

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Table 14: Aviation—ATSB recommendations closed in 2016–17

Investigation

AR-2012-034: Loss of separation between aircraft in Australian airspace: 2008 to June 2012

Safety issue

Regulatory oversight processes for military air traffic services do not provide independent assessment and assurance as to the safety of civilian aircraft operations.

Number

AR-2012-034-SR-015

Organisation

Civil Aviation Safety Authority (CASA)

Recommendation

The ATSB recommends that CASA should review the results of this report and determine whether its current level of involvement with military air traffic services (ATS) is sufficient to assure itself that the safety of civil aircraft operations while under military ATS control is adequate.

Released

18 October 2013

Final action

30 September 2016

Final action

Since this safety recommendation was issued, CASA and Defence have been collaborating and through the Aviation Policy Group (APG) have jointly developed a policy covering the safety oversight of civil operations into joint user and military airports.

The policy comprises a subordinate agreement to the primary CASA/Defence agreement on safety and airworthiness. The APG, at the 8 September 2016 meeting, endorsed the subordinate agreement and it was subsequently signed by CASA Director of Aviation Safety and the Chief of Air Force. The subordinate agreement is titled Topic area: transparency of safety oversight of delivery of Defence ATS to civil aviation operations, and CASA and Defence have now commenced implementation of the arrangements.

The ATSB notes the scope of the agreement is: Defence continues to provide its own safety oversight of the provision of ATS to civil aviation operations. CASA will observe systems and operational assessments conducted by Defence of Defence ATS operations, and engage in Defence regulatory discussions and forums, to the degree necessary to satisfy CASA that the level of Defence safety oversight and delivery of ATS to civil aircraft is comparable to that provided under CASR Part 172.

Further, the ATSB notes activities in the agreement are:

  1. Identification of specific CASA and Defence personnel/appointments to form the focal points.
  2. Standing participation of CASA focal points at the periodic Defence ATM Airworthiness Boards (AWB), with access to relevant AWB documentation. CASA will provide the AWB with a general report including matters of safety interest to CASA and all CASA observations applicable to civil aircraft operations at joint user and military airports and within military administered airspace.
  3. Regular participation by CASA focal points in Defence ATM Operational Evaluations (OPEVAL) and other regulatory or surveillance activities which may include coordination with applicable Defence aviation stakeholders:
    1. CASA will not formally assess Defence personnel, ATC procedures or systems and infrastructure at these events;
    2. b) CASA will raise with Defence any matters of safety interest identified by CASA in the context of CASR Part 172 as applicable to the operation of civil aircraft within Defence aviation environments;
    3. CASA will track participation in Defence OPEVAL and other regulatory activities through CASA’s Sky Sentinel software application, recording any safety concerns identified to Defence as CASA ‘Observations’ within Sky Sentinel; and
    4. Defence will address any CASA recommendations and Observations and respond accordingly, consulting, where applicable, with aviation users in order to pursue an optimal outcome.
  4. In order to enhance Defence understanding of the practical application of CASR Part 172 in the civil environment, subject to CASA coordination with, and approval by, Airservices Australia on a case-by-case basis, regular observation by Defence focal points of CASA surveillance activities at selected civil ATC locations.
  5. Mutual participation in CASA and Defence regulatory discussions and forums to facilitate the transparency of safety oversight of civil operations at joint user and military airports and within military administered airspace.

Additional actions in support of the transparency of oversight agreed by the APG include that: the primary CASA/Defence Safety and Airworthiness agreement and the subordinate agreement be published on each agency website for the next two years; CASA and Defence provide regular updates to the APG on the implementation of the arrangements and activities conducted; re-evaluation of the arrangements take place after two years, involving Defence, CASA, Airservices Australia and the Department of Infrastructure and Regional Development, and the outcomes and proposed actions be reported to the APG.

As a result of the implementation of the subordinate agreement and the complementary additional actions agreed by the APG, CASA considers that Safety Recommendation AR-2012-034-SR-015 has been addressed. The ATSB welcomes this landmark agreement between CASA and Defence as a positive and transparent approach to cooperation that should ensure that CASA can assure itself of the safety of civilian aircraft in military airspace. The ATSB has closed this recommendation.

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Table 15: Marine—ATSB recommendations closed in 2016–17

Investigation

MO-2014-008: Engine room fire on board the bulk carrier Marigold, Port Hedland, Western Australia, 13 July 2014

Safety issue

The emergency response plans for a ship fire in Port Hedland did not clearly define the transfer of control procedures for successive incident controllers from different organisations or contain standard checklists for their use.

Number

MO-2014-008-SR-040

Organisation

West Australian Department of Fire and Emergency Services (DFES)

Recommendation

The ATSB recommends that the DFES takes action to address the safety issue with regard to transfer of control procedures for incident controllers from different organisations.

Released

20 April 2016

Final action

12 July 2016

Final action

Whilst DFES agree that action is required to address issues regarding transfer of control procedures during marine fire incidents, DFES does not agree that it has responsibility for this action.

The Hazard Management Agency (HMA) for Marine Transport Emergencies (MTEs) in Western Australia is the Department of Transport (DoT). As part of their HMA responsibilities, DoT has developed the State Hazard Plan for Marine Transport Emergency, which prescribes that:

The Port Authorities Act 1999 and relevant agreement acts require Port Authorities and private companies operating ports (Maritime Export Facility) to prepare, maintain and implement a Marine Safety Plan that is approved by the Minister for Planning and Infrastructure in the case of Port Authorities.

The Director General of DoT approves such plans in the case of ports (Marine Export Facilities) operated by private companies. These plans will identify arrangements for managing Marine Transport Emergency situations within port waters.

Whilst encouraging consultation and coordination in the development of Port Marine Safety Plans, DFES is of the view that ultimate responsibility for addressing the issues identified rests with Pilbara Ports and BHP Billiton.

Notwithstanding the above, DFES has actively and regularly liaised with Pilbara Ports in relation to emergency management arrangements since the MV Marigold incident.

Investigation

MO-2014-008: Engine room fire on board the bulk carrier Marigold, Port Hedland, Western Australia, 13 July 2014

Safety issue

The large size and weight of the ship firefighting cache made it difficult for the duty Port Hedland volunteer firefighter to transport it to the wharf.

Number

MO-2014-008-SR-043

Organisation

West Australian Department of Fire and Emergency Services (DFES)

Recommendation

The ATSB recommends that the DFES takes action to address the safety issue with regard to transporting ship firefighting caches to wharves.

Released

20 April 2016

Final action

12 July 2016

Final action

DFES agree with this recommendation and is taking steps to break the caches down into smaller portable packages.

As a general comment, DFES is disappointed to note that the risks related to the safety standards of ships operating in Western Australian ports have not been addressed from a regulatory/compliance perspective.

DFES note that this is the second shipboard fire in the Pilbara in recent years where the presence of hatches that were secured open or defective have affected the performance of deluge systems and hampered fire suppression efforts. These two occurrences suggest, anecdotally at least, that this is a commonplace issue within the industry.

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Table 16: Rail—ATSB recommendations closed in 2016–17

Investigation

RO-2014-005: Fatality at Heyington railway station, Toorak, Victoria, 22 February 2014

Safety issue

The train door open/close indicator on the driver’s control console was inadequate as a warning device once the traction interlock had deactivated.

Number

RO-2014-005-SR-031

Organisation

Metro Trains Melbourne (MTM)

Recommendation

The ATSB recommends that MTM considers incorporating an additional warning device to heighten driver awareness that the train doors have not closed, if automatic deactivation is retained.

Released

13 August 2015

Final action

26 July 2016

Final action

Given the circuit modification and provision of a manual key-operated switch described in response to Action No–RO-2014-005-SR-030, this action is no longer applicable.

Safety recommendations released in 2016–17

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Table 17: Aviation—Safety recommendations released in 2016–17

Investigation

AO-2014-053: Collision with terrain involving Cessna 206, VH-FRT, Caboolture Airfield, Queensland, 22 March 2014

Safety issue

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.

Number

AO-2014-053-SR-017

Organisation

Civil Aviation Safety Authority (CASA)

Safety recommendation

The ATSB recommends that CASA takes action to strengthen incorporation of Cessna Single Engine Service Bulletin SEB07-5 secondary seat stop modification.

Released

23 June 2017

Investigation

AO-2014-053: Collision with terrain involving Cessna 206, VH-FRT, Caboolture Airfield, Queensland, 22 March 2014

Safety issue

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.

Number

AO-2014-053-SR-018

Organisation

Civil Aviation Safety Authority (CASA)

Safety recommendation

The ATSB recommends that CASA, in conjunction with the Australian Parachute Federation, takes action to increase the usage of dual-point restraints in parachuting aircraft that are configured for rear facing occupants.

Released

23 June 2017

Investigation

AO-2014-053: Collision with terrain involving Cessna 206, VH-FRT, Caboolture Airfield, Queensland, 22 March 2014

Safety issue

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.

Number

AO-2014-053-SR-019

Organisation

Australian Parachute Federation (APF)

Safety recommendation

The ATSB recommends that the APF, in conjunction with CASA, takes action to increase the usage of dual-point restraints in parachuting aircraft that are configured for rear facing occupants.

Released

23 June 2017

Investigation

AO-2014-053: Collision with terrain involving Cessna 206, VH-FRT, Caboolture Airfield, Queensland, 22 March 2014

Safety issue

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.

Number

AO-2014-053-SR-020

Organisation

Civil Aviation Safety Authority (CASA)

Safety recommendation

The ATSB recommends that CASA introduce risk controls to parachuting operations that provide increased assurance of aircraft serviceability, pilot competence and adequate regulatory oversight.

Released

23 June 2017

Investigation

AO-2015-114: Runway excursion involving Cessna 550, VH-FGK, Lismore Airport, New South Wales, 25 September 2015

Safety issue

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.

Number

AO-2015-114-SR-002

Organisation

Textron Aviation (Cessna)

Safety recommendation

The ATSB recommends that Textron Aviation (Cessna) take safety action to address the fact that Citation aircraft do not have an annunciator light to show that the parking brake is engaged and the Cessna ‘before take-off’ checklist does not include a check to ensure the parking brake is disengaged.

Released

25 July 2016

Investigation

AO-2014-032: In-flight pitch disconnect involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, New South Wales, 20 February 2014

Safety issue

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 the loads resulting from a pitch disconnect.

Number

AO-2014-032-SR-014

Organisation

ATR (aircraft manufacturer)

Safety recommendation

The ATSB recommends that ATR complete the assessment of transient elevator deflections associated with a pitch disconnect as soon as possible to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that ATR take immediate action to ensure the ongoing safe operation of ATR 42/72 aircraft.

Released

5 May 2017

Investigation

AO-2014-032: In-flight pitch disconnect involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, New South Wales, 20 February 2014

Safety issue

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 the loads resulting from a pitch disconnect.

Number

AO-2014-032-SR-015

Organisation

European Aviation Safety Agency (EASA)

Safety recommendation

The ATSB recommends that EASA monitor and review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that EASA take immediate action to ensure the ongoing safe operation of ATR 42/72 aircraft.

Released

5 May 2017

Investigation

AO-2014-032: In-flight pitch disconnect involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, New South Wales, 20 February 2014

Safety issue

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 the loads resulting from a pitch disconnect.

Number

AO-2014-032-SR-016

Organisation

Civil Aviation Safety Authority (CASA)

Safety recommendation

The ATSB recommends that CASA review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect, to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that CASA take immediate action to ensure the ongoing safe operation of Australian-registered ATR 42/72 aircraft.

Released

5 May 2017

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Table 18: Marine—Safety recommendations released in 2016–17

Investigation

MO-2015-005: Fatal injury on board Skandi Pacific

Safety issue

Skandi Pacific’s managers had not adequately assessed the risks associated with working on the aft deck of vessels with open sterns, including consideration of engineering controls to minimise water being shipped on the aft deck.

Number

MO-2015-005-SR-006

Organisation

DOF Management, Norway

Safety recommendation

The ATSB recommends that DOF Management take further action to adequately address the safety issue concerning the use of vessels with open sterns.

Released

23 November 2016

Investigation

MO-2016-001: Breakaway of Spirit of Tasmania II, Station Pier, Port Melbourne, Victoria, 13 January 2016

Safety issue

While TT-Line Company’s standard mooring line pattern for ships at Station Pier had been successfully used for many years, the breakaway indicated the risk could have been further reduced to better prepare for such unusual circumstances.

Number

MO-2016-001-SR-005

Organisation

TT-Line Company

Safety recommendation

The ATSB recommends that TT-Line Company take necessary action to adequately address the safety issue following the completion of its mooring analysis.

Released

11 May 2017

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Table 19: Rail—Safety recommendations released in 2016–17

Investigation

RO-2014-016: Collision between V/Line train 8280 and MTM train 6502 at Altona, Victoria, 22 August 2014

Safety issue

The rules pertaining to passing a permissive signal at stop place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.

Number

RO-2014-016-SR-38

Organisation

Metro Trains Melbourne (MTM)

Safety recommendation

The ATSB recommends that MTM consider additional risk mitigation measures to maintain train separation where the safeworking system allows permissive working.

Released

6 July 2016

Investigation

RO-2014-016: Collision between V/Line train 8280 and MTM train 6502 at Altona, Victoria, 22 August 2014

Safety issue

The marker lights on some Metro Trains Melbourne passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.

Number

RO-2014-016-SR-39

Organisation

Metro Trains Melbourne (MTM)

Safety recommendation

That MTM institute measures to ensure that the luminous intensity of marker lights of all passenger trains in their fleet meet a railway industry approved and accepted standard.

Released

6 July 2016

Investigation

RO-2015-009: Signals passed at danger by train 1240 at Marshall (Geelong), Victoria, 29 May 2015

Safety issue

The rule describing the required driver response to a distant signal at caution in a two-position signalling system did not fully reflect the signalling system design principles.

Number

RO-2015-009-SR-029

Organisation

V/Line Regional Network and Access

Safety recommendation

That V/Line amends the rule for the required driver response to a distant signal at caution. The amendment should bring the rule into alignment with the signalling system design principles.

Released

12 December 2016

Investigation

RO-2016-007: Derailment of freight train 9305 at Katunga, Victoria, 30 May 2016

Safety issue

The inspection regime to identify rail fractures was ineffective for the condition of this track.

Number

RO-2016-007-SR-001

Organisation

V/Line Pty Ltd

Safety recommendation

The ATSB recommends that V/Line completes the risk review and implements safety actions to reduce the likelihood of derailment following a rail fracture.

Released

30 May 2017

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Table 20: Safety advisory notices released in 2016–17

Investigation

AO-2014-164: Collision with terrain involving Van’s RV-6A, VH-JON, 8 km south of Moorabbin Airport, Victoria, 14 October 2014

Safety issue

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.

Number

AO-2014-164-SAN-012

Organisation

Pilots operating canopy-equipped aircraft

Safety advisory notice

The consequences when an aircraft canopy opens in-flight, including other than Van’s aircraft types, can vary from being relatively benign to significant, such as a sudden pitch down. In any event, in the first instance pilots should expect an element of startle and distraction. The detection of an unsecured canopy prior to take-off could prevent in-flight control issues resulting in injury or aircraft damage. The ATSB advises pilots to be vigilant and confirm the security of their aircraft’s canopy prior to take-off.

Released

25 November 2016

Investigation

AO-2016-028: Ground handling occurrence involving Airbus A330, 9M-MTB, Melbourne Airport, Victoria, 31 March 2016

Safety issue

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.

Number

AO-2016-028-SAN-006

Organisation

Organisations that work airside and aircraft operators

Safety advisory notice

Effective coordination and communication between airside crews can prevent or detect mistakes that could otherwise lead to damage or injury. The ATSB advises organisations that work airside and aircraft operators to ensure that ground and flight crew activities are harmonised, and to foster active communication and coordination between working crews.

Released

13 September 2016

Investigation

AO-2017-032: In-flight propeller malfunction involving SAAB 340 VH-NRX, 10NM SW of Sydney Airport, 17 March 2017

Safety issue

The propeller shaft currently has no inspection methods to detect a fatigue failure originating from the propeller side of the dowel.

Number

AO-2017-032-SAN-001

Organisation

General Electric

Safety advisory notice

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 to their own operation.

Released

13 April 2017

Investigation

MO-2015-005: Fatal injury on board Skandi Pacific

Safety issue

Skandi Pacific’s managers had not adequately assessed the risks associated with working on the aft deck of vessels with open sterns, including consideration of engineering controls to minimise water being shipped on the aft deck.

Number

MO-2015-005-SAN-005

Organisation

DOF Management

Safety advisory notice

The ATSB advises the masters, owners and operators of all offshore support vessels to ensure that the risks posed by the open sterns of some of these vessels are adequately assessed.

Released

23 November 2016

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