Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 1 October 2020, at about 0800 Eastern Standard Time, the crew of a Jetstream 32 were preparing to depart from Canberra, Australian Capital Territory, on a scheduled passenger flight to Ballina, New South Wales. As the luggage was being loaded onto the aircraft, the captain observed smoke and fire emanating from a piece of baggage. The captain removed the baggage and aerodrome fire services were called to extinguish the fire. The source of the fire was determined to be an e-cigarette and battery pack, which had subsequently ignited.
Safety message
This incident highlights the importance of ensuring that all items taken on board an aircraft do not pose a safety risk to the flight. E-cigarettes can be taken in a passenger’s carry-on luggage, however, cannot be checked in. Spare batteries must also be taken as carry-on luggage only and be individually protected so as to prevent short circuits or by placing each battery in a separate plastic bag or protective pouch. More information regarding dangerous goods can be found on the CASA website, including the Can I pack that? dangerous goods app for passengers.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 16 August 2020, at about 2145 Central Standard Time, a Bell 412 helicopter was conducting a medical retrieval from a farm in Lower Light, South Australia. The helicopter was to land at an unprepared helicopter landing site in an open paddock to the east of the house. As the approach was being conducted in near dark night conditions (8 per cent celestial illumination), the crew of the helicopter were in contact with the Country Fire Service (CFS) crew including a helicopter landing officer, who were at the site identifying any potential obstacles. The CFS crew identified wires running alongside the road next to the paddock, but no wires were observed in the paddock.
The helicopter crew were using night vision goggles and searchlights to assist with visibility. Additionally, the CFS vehicles illuminated the landing spot. The pilot conducted two orbits of the area to allow the crew to identify possible obstacles around the landing site. The crew did not detect any obstacles and the pilot commenced descent. Passing approximately 50 ft above ground level, the pilot identified a single-wire earth return (SWER) wire running perpendicular to the approach path. After identifying the wire, the pilot announced ‘wires’ and conducted a right turn, subsequent approach and entered a hover to clear any obstacles. The crew used an appropriate approach profile that allowed an effective go-around procedure to be conducted.
Upon landing, it was identified the CFS crew had inadvertently set their vehicles and the lights directly below the SWER line. The power poles were obscured in trees and located approximately 350 m from the paddock’s border.
Safety action
As a result of this occurrence, the operator has advised the ATSB that they have taken the following safety actions:
Highlighted the incident to company aircrew, noting the wire was detected on short finals at a profile that allowed for evasive action to take place.
Highlighted to company aircrew that any helicopter landing site advice provided by external agencies is to be considered as ‘for information only’.
Reviewed the crew flight safety training video and recency requirements for helicopter landing officers.
Safety message
Wires are difficult to sight and often in the most unexpected places in rural areas. The ATSB research report Avoidable Accidents No. 1 – Low level flying (AR-2009-041) provides information on wire hazards associated with flight below 500 ft.
Although extensive obstacle identification had taken place by both the crew of the helicopter and the CFS crew on the ground, this wire was unable to be sighted until the helicopter was on final approach. This occurrence highlights the importance of maintaining an awareness and lookout for powerlines during low-level operations. Property owners are also reminded that they can contact power companies to have wires marked if they present a hazard to low-level operations.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 6 September 2020, a Beechcraft G36 departed Colina for a private flight to Lake Keepit, New South Wales. There was one pilot and five passengers on board.
On arrival at Lake Keepit, ground personnel advised the pilot that there was a glider and tow vehicle on the threshold of runway 14. They had been towed into place to prepare for departure in 30 minutes.
The aircraft then joined midfield crosswind for runway 14. During approach, the pilot became distracted by the glider and tow vehicle on the runway and forgot to complete the approach and landing checklist. As a result, the landing gear was not extended and the aircraft landed with the wheels retracted. The aircraft sustained minor damage to the underbelly and propeller (Figure 1).
Figure 1: Aircraft after landing
Source: The Gliding Federation of Australia
Safety message
This incident highlights the importance of managing distractions and being vigilant during critical phases of flight. Distractions can result in critical tasks being omitted and not being detected until it is too late.
Wheels-up landings are not uncommon; the Flight Safety Australia article, Those who won’t: avoiding gear-up landings includes valuable information to assist pilots in avoiding these incidents.
In addition to landing wheels up, the aircraft landed on an occupied runway. Pilots need to ensure the runway is clear before conducting an approach to land.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 12 September 2020, the pilot of a Cessna 188 was conducting aerial application operations on a crop near Urana township, New South Wales. The pilot had just completed the final planned spray pass and, after observing a small amount of chemical remaining in the hopper, decided to spray the remainder in an extra pass. The selected run included two sets of known powerlines from the previous operation with a T-intersection running across the planned spray run (Figure 1). Another company aircraft was operating nearby and the pilot contacted them by radio to advise them of the change of plans and to organise separation. Approaching the run, the pilot identified the powerlines, and turned their attention to the other company aircraft to ensure separation for the run.
With their focus momentarily diverted, the pilot commenced an unplanned descent prior to the T-intersection in the wires. The pilot reported being aware of the crossing wire but did not observe the powerline prior to contact, striking the lines with the undercarriage gear legs. The wire-cutters fitted to the gear legs cut the first wire but were ineffective on the second wire with the aircraft decelerating rapidly and pitching towards the ground.
The aircraft collided with terrain in a level attitude, coming to rest in the paddock 70 m from the strike location and the pilot exited the aircraft uninjured. The aircraft was substantially damaged.
Figure 1: Flight path and powerline location
Source: Look up and live web application. Annotated by the ATSB.
Safety message
Wirestrikes pose an on-going hazard to aerial agricultural operations. Between 1 January 2015 and 12 September 2020, 154 wirestrike occurrences were reported to the Australian Transport Safety Bureau (ATSB). Of these, 102 strikes were recorded during aerial agricultural operations with 21 of the occurrences resulting in an accident. Previous research by the ATSB has shown that 63 per cent of pilots involved in a wirestrike accident were aware of the location of the wire before they struck it. (Aviation Research and Analysis Report – B2005/0055)
This accident highlights the dangers of distractions and last-minute change of plans, especially those made inflight during low-level operations. The ATSB has released, in association with the Aerial Agriculture Association of Australia, an educational booklet, Wirestrikes involving known wires: A manageable aerial agriculture hazard (AR-2011-028). This booklet contains numerous wirestrike accidents, the lessons learnt from them and suggestions to safely manage low-level flying Inflight decision making is one of the ATSB’s major safety concerns.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 4 September 2020 at 1300 Eastern Standard Time, a pilot and instructor were conducting training in a Piper PA-31-325, 9 NM south of Cambridge, Tasmania. The instructor was training the pilot with a simulated engine fire, including engine shutdown, feathering of the propeller and cross feeding of fuel.
Once the simulated exercise began, the pilot worked through the checklist for securing an inoperative engine. The pilot completed the checklist, which included closing the firewall shut-off lever, closing the throttle and feathering the propeller. The pilot then began going through the stages of returning the aircraft to normal flight operations. While they were unfeathering the propeller, the revolutions per minute of the propeller unexpectedly accelerated and the pilot returned it back to the feathered stage. Engine power could not be restored, and the instructor made the decision to shut down the no.1 engine. The pilot suggested diverting the aircraft to Hobart. The instructor agreed and contacted air traffic control, declaring a PAN PAN[1] before diverting the aircraft to Hobart. The aircraft landed safely and was met by engineers from the instructor’s company.
During the post-flight inspection, engineers discovered that the no.1 engine firewall shut-off lever was still in the closed position. When the training exercise was over, the firewall shut-off lever should have been in the open position. Because of this, the no.1 engine was unable to return to full power during the unfeathering procedure, which subsequently led to the in-flight engine shutdown.
Safety message
This incident highlights the importance of pilots having a good working knowledge of aircraft systems and checklists prior to practicing emergency procedures. In this instance, the checklist for unfeathering the engine did not include a check of the firewall shut-off lever. As a result, the firewall shut-off lever was left in the closed position, resulting in the loss of engine power.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
At about 1117 Eastern Standard Time on 29 August 2020, a Piper PA-28 departed Bankstown Airport, New South Wales (NSW) for a private flight, tracking to Bathurst, NSW under the visual flight rules. After departure, the pilot of the PA-28 commenced a shallow climb with the intention of remaining clear of the Sydney control area steps. However, at approximately 26 NM west of Sydney, the pilot inadvertently entered controlled airspace without a clearance.
A short distance ahead and above the PA-28, a Cirrus SR20 was on a private flight from Bankstown Airport, NSW to Dubbo Airport, NSW under the instrument flight rules. The SR20 was on climb to 6,000 ft in class C airspace when the aircraft’s traffic advisory system alerted the pilot to the presence of the PA-28. The traffic advisory system indicated the PA-28 was climbing towards the aircraft in the 6 o’clock position relative to the SR20. The positioning of the two aircraft prevented the SR20 pilot from sighting the PA-28. The SR20 pilot queried the proximity of the PA-28 with Air Traffic Control (ATC). ATC then identified the conflict and issued a safety alert to the SR20.
At about 1127 EST, the SR20 and PA-28 came into close proximity, with separation between the two aircraft reduced to 0.8 NM laterally and 300 ft vertically. ATC made a broadcast to the unverified PA-28 informing the pilot of the airspace infringement and issuing turn instructions to regain separation. The PA-28 was observed by ATC to follow the separation instructions and commence a turn to the left. The conflict was subsequently resolved, and the PA-28 exited controlled airspace.
Safety message
This incident highlights the importance of maintaining navigational accuracy and traffic awareness when operating in close proximity to control area steps. It also illustrates the value of enhanced situational awareness provided by airborne traffic advisory systems such as that fitted to the involved Cirrus SR20.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 3 August 2020, a Robinson R44 helicopter was conducting fire surveillance and abatement operations about 50 NM east of Jabiru, Northern Territory. In the early afternoon, the helicopter landed and shutdown in a pre-arranged temporary landing site waiting to pick up three ground personnel. At about 1700 Central Standard Time, once the personnel and their equipment was secured, the helicopter was started and brought into a hover. After checking the power available, a vertical take-off and climb was conducted until the helicopter was approximately 75 ft above ground level when a translation to forward flight commenced. The direction chosen was the most suitable available when considering terrain and wind direction.
As the pilot commenced the translation into forward flight over a treed area, the helicopter initially maintained height but as the pilot increased collective[1] the rotor RPM began to decay. The pilot increased the throttle and lowered the collective in an attempt to regain rotor RPM. As the helicopter descended, the collective was again raised in an attempt to arrest the descent, however the low rotor RPM warning horn sounded. A further attempt to recover the rotor RPM by lowering the collective was unsuccessful leaving a forced landing as the only option available for the pilot.
A landing site was selected in the treed area and the helicopter settled onto the ground resulting in a heavy landing. The main rotor blades struck several branches as the helicopter came through the tree canopy resulting in minor damage to the blades. After securing the helicopter, the pilot and ground personnel exited the helicopter and moved a safe distance away. The heavy landing activated the inertia switch on the emergency locator transmitter.[2]
Figure 1: The helicopter in situ after the forced landing
Source: Operator
Operator’s investigation
The operator conducted an investigation into the circumstances surrounding this accident that revealed several contributing factors that are summarised below:
The aircraft was within the maximum take-off weight limits however it was close to the performance limit for an out of ground effect[3] hover in the prevailing weather conditions.
The afternoon weather conditions had changed from both previous days and earlier that day. This was the first afternoon in approximately four months that there was a tropical build up with variable and quickly changing winds as opposed to the consistant south easterly winds associated with the dry season. The afternoon was hotter and more humid than previous days.
The helicopter was over-pitched to a degree that successful recovery in the circumstances was not possible.
Hover performance is essentially a product of engine power available and engine power required. The main factors affecting engine power required in a hover are helicopter weight, density of air and proximity to the ground (ground effect).
To maintain a steady high hover or climb vertically, the helicopter requires more main rotor thrust to act as lift, which in turn requires more engine power.
As air density decreases with an increase in altitude, temperature, and to a lesser degree humidity, a normally aspirated engine produces less power. Additionally, if the same amount of rotor thrust is needed, the rotor blades need a higher angle of attack, which creates more drag and generates a requirement for more engine power.
When a helicopter is hovering within about one rotor diameter[4] of the ground, the performance of the main rotor is affected by ground effect. A helicopter hovering in-ground-effect requires less engine power to hover than a helicopter hovering out-of-ground-effect.
Safety action
As a result of this occurrence, the operator has advised the ATSB that they are taking the following safety actions:
It was identified post occurrence that there were some training and recency issues that were addressed particularly in the correct recovery actions for a low rotor RPM situation and the technique used to translate into forward flight from a vertical take-off or an OGE hover.
The operator has limited the number of ground personnel to a maximum of two providing a larger power margin available for operating in these situations.
All pilots have undertaken a flight review to identify and analyse any skill or knowledge deficiencies.
Safety message
This accident serves as a reminder that when operating helicopters from unprepared landing sites, pilots should consider the approach and departure routes available in conjunction with operational constraints, weather, performance available and possible emergency recovery. Time spent considering and confirming the fundamental factors of decision-making, helicopter performance and limitations and the consideration of actions in the event of performance limitations or an emergency may help prevent injury to crew and damage to, or loss of, an aircraft.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 9 July 2020, the student pilot of a Diamond DA40 was preparing the aircraft for a local solo flight from Parafield Airport, South Australia. As this was the student’s first solo navigational flight, the instructor assisted the student with the pre-flight inspection.
The instructor signalled for the fuel truck to come and refuel the aircraft. As the fuel truck was busy refuelling another aircraft at the time, the instructor left the student to complete the pre-flight inspection and refuel the aircraft.
After completing the pre-flight inspection, the student left the aircraft unattended to go to the office to collect their flight bag and gear and returned shortly after, with the assumption that the aircraft had been refuelled. The student did not check the fuel tanks or conduct a fuel drain, and departed Parafield for the navigational flight.
During cruise at 4,500 ft, approximately 18 NM from Parafield, the student received a low fuel warning. Approximately 30 minutes later, a second low fuel warning sounded and it was at this point in time that the student conducted a return to Parafield for an uneventful landing.
The post-flight inspection revealed that the aircraft landed outside the prescribed fuel reserves.
Operator investigation findings
Following the incident, the operator conducted an internal investigation and provided the ATSB with the following:
The student believed that the fuel tanks were full from the outset, influencing their judgement throughout the process.
When the student was alerted to a low fuel warning in the current tank, they correctly and immediately selected the other tank, but did not calculate the total on-board fuel. The decision was further influenced by the student’s belief that the fuel content indicator was not always accurate. This was remnant of a previous aircraft the student flew and not the DA40.
When the student was alerted by a low fuel warning on the second tank, they elected to discontinue the flight, but not to use the alternate airport. This resulted in a return to Parafield with the fuel contents remaining below that of the fixed reserve.
Safety message
This incident highlights the importance of ensuring that all pre-flight inspections and checklists are carried out systematically. Fuel quantity and quality should always be checked before each flight and after refuelling to ensure there is a correct amount of fuel on board the aircraft to conduct the flight.
It also reiterates the importance of being familiar and proficient with aircraft system, including the risks and controls associated with fuel management.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On 18 July 2020, at about 1000 Eastern Standard Time, a Piper PA-28 was taxiing to vacate the runway at Warrnambool Airport, Victoria. As the aircraft vacated the runway, the pilot proceeded towards the fuel bowser and aligned the aircraft on what was thought to be a taxiway guideline for the apron in front of the fuel bowser. As the aircraft slowed, it suddenly veered right and came to a stop. The right wing had contacted the shelter housing the fuel bowser, with further inspection revealing a dent in the leading edge of the wing. The pilot had mistaken the parking limit line for a taxi guideline marking and positioned the aircraft too far to the right, resulting in a collision with the structure as the aircraft approached the bowser (see Figure 1).
Figure 1: Warrnambool Airport apron markings
Source: Google annotated by the ATSB
As depicted in Figure 2 from the Manual of Standards Part 139 – Aerodromes Volume 1: Chapter 8, limit markings differ in presentation from taxi guideline markings. Taxi guidelines consist of a single solid yellow line, whereas parking limit lines consist of two solid yellow lines surrounding a solid red line with the words ‘Parking Clearance’ appearing at regular intervals. A list of markings and their meanings are available to pilots in the Aeronautical Information Publication (AIP) AD 1.1 4.10.
Figure 2: Apron markings – taxi guideline marking and parking clearance line
Source: Manual of Standards Part 139 - Aerodromes
Safety message
This incident reinforces the importance of maintaining situational awareness[1], a good lookout while taxiing and a familiarity with apron markings.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
What happened
On the afternoon of 9 July 2020, a Beechcraft A36 departed Lark Quarry in Central Queensland to conduct a private flight to Gympie, Queensland. There was a pilot and three passengers on board. The pilot received the en route weather forecast on the morning of departure, approximately 10 hours prior to the actual flight time due to lack of phone coverage in the area. The weather report at that point in time was suitable for a flight under VFR.[1]
During the flight, the weather began to deteriorate closer to the coast as the aircraft neared its planned destination. The pilot observed increasing overcast cloud on the intended track and commenced a descent from 9,500 ft to remain clear of cloud. The aircraft levelled at 4,500 ft, which appeared to be well below the cloud base.
A short time later, the aircraft entered cloud and the pilot lost all visual references. The pilot immediately contacted air traffic control (ATC) and declared a PAN PAN[2] to request assistance, while commencing a climbing turn onto a reciprocal heading. The climbing turn enabled the aircraft to regain VMC[3] after about two minutes in cloud.
The pilot then conducted a diversion to Mundubbera, Queensland and was able to maintain VMC for the remainder of the flight.
Figure 1: VMC criteria for aeroplanes in Class G airspace
Source: Aeronautical Information Publication (AIP) Australia: ENR 1.2-4 14 May 20
Pilot comments
The pilot advised the ATSB that they had a pre-planned course of action for the situation of inadvertently flying into weather that was less than VMC. An important part of this plan was to immediately notify ATC of the situation to ensure all possible assistance was gained. The pilot committed to this plan and carried it out to effect a safe recovery.
Obtaining weather forecasts
The AIP ENR 1.10 Section 1.2.2 states:
Flights for which a forecast is required and cannot be obtained, are permitted to depart provided the pilot is satisfied that the weather at the departure point will permit the safe return of the flight within one hour of departure. The flight is permitted to continue if a suitable forecast is obtained for the intended destination within 30 minutes after departure.
Source: Visual Flight Rules Guide 14 May 20
If the pre-flight briefing is obtained more than one hour before the flight, the pilot should obtain an update before departure to ensure that the latest information available can be used for the flight.
Pilots can obtain forecasts and updates by radio en route if other forms of communication are unavailable.
Safety message
Obtaining the latest valid weather forecasts during the pre-flight planning phase is paramount to the safe conduct of a longer-distance VFR flight. Pilots are encouraged to make conservative decisions when considering how forecast weather may affect their flight. If poor weather is encountered en route, timely and conservative decision-making may be critical to ensuring a safe outcome.
VFR pilots are also encouraged to familiarise themselves with the definition of VMC criteria and carefully consider available options where forecast or actual conditions are such that continued flight in VMC cannot be assured.
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
