Aviation safety issues and actions

Hazard identification

Issue number: AO-2018-078-SI-02
Issue owner: Airlines of Tasmania [Par Avion]
Transport function: Aviation: Air transport
Background: Investigation Report AO-2018-078
Issue release date: 20 December 2021
Current issue status: Closed – Adequately addressed
Issue status justification:

Safety actions taken by Airlines of Tasmania removes the safety issue.

Safety issue description

Airlines of Tasmania's safety management processes for identifying hazards extensively relied on safety reports. This limited the opportunity to proactively identify the risks in all operational activities, and assess the effectiveness of any controls in place.

Proactive action

Action number: AO-2018-078-NSA-062
Action organisation: Airlines of Tasmania [Par Avion]
Action status: Closed

Airlines of Tasmania performed a risk assessment for the south-west operations and identified a number of hazards. These appeared on a hazard and risk register, under flight operations, and included:

  • Operating in Tasmania challenging conditions: This was initially rated as medium, but was reduced to low with the controls that the pilot holds a commercial pilot licence, and non‑structured in-command under supervision until the standard is achieved.
  • Weather – other: Examples include unforecast reduced visibility, low cloud etc. This had an initial rating of medium, but was reduced to low with the controls of access to up-to-date forecasts available 24 hours at every destination, training and checking, proficiency checks and flight reviews, and in-flight alerts from Airservices Australia.

The operator also advised that there had been significant emphasis on making the safety management system more proactive, by assessing risk from external sources. This included:

  • Increased trend monitoring to identify potential issues early.
  • Increased visibility of who was accessing internal safety alerts, to allow the safety manager to follow up with those who were not reading reports.
  • An increase in the number of hazards entered into the hazard register.
  • Pilots were instructed to ‘submit a safety report on any flight in which you required a deviation from the intended plan, i.e., holding or diverting around weather. This provides a good record in the safety management system of how we practically manage risk’.
  • A new section has been added to the SMS regarding weather assessment criteria, whereby when the aviation forecast indicates conditions below certain parameters, pilot must contact a senior pilot to seek authorisation for the flight to go ahead.
  • Regular staff meetings to receive feedback about issues, which management could address.
Last update 20 December 2021