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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: AO-2021-023-SI-01Inadequate traffic alert and collision avoidance training Number: AO-2021-023-SI-01 Description: AO-2021-023-SI-01:The helicopter operator's traffic alert and collision avoidance system knowledge was inadequate with respect to resolution advisory alert terrain considerations and the required intensity of response manoeuvring. Issue owner: Babcock Mission Critical Services Australia Operation affected: Aviation: General aviation	Date, status, type Date: 27 May 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2020-038-SI-01External aircraft white lighting Number: AO-2020-038-SI-01 Description: AO-2020-038-SI-01:The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height., This delayed the identification and recovery from the unsafe aircraft state resulting in the pilot not identifying the developing rate of descent during the incident, delaying ... Issue owner: Helicorp Pty Ltd Operation affected: Aviation: Air transport	Date, status, type Date: 08 Apr 2022 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: AO-2020-012-SI-01ERSA procedure Number: AO-2020-012-SI-01 Description: AO-2020-012-SI-01:The En-Route Supplement Australia included a requirement to add 1,000 ft to the prescribed practice instrument approach ‘altitude’ at Mangalore Airport. The procedure did not detail whether this height was to be applied to the minimum descent altitude or to all approach altitudes, resulting in varied application and an increased ... Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: General aviation	Date, status, type Date: 31 Mar 2022 Status: Open – Safety action pending Type: Safety recommendation
Issue, description, who it affects Issue: RO-2019-009-SI-004Management of late-notice roster changes Number: RO-2019-009-SI-004 Description: RO-2019-009-SI-004:Queensland Rail’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes. Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 29 Mar 2022 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2019-009-SI-001Placement of signal aspect indicators at station platforms Number: RO-2019-009-SI-001 Description: RO-2019-009-SI-001:Queensland Rail's process for the installation of signal aspect indicators (SAIs) did not provide sufficient detail to ensure consistent and conspicuous placement of SAIs at station platforms. This problem, combined with an SAI’s non-salient indication when the platform departure signal displayed a stop indication, increased the risk that an SAI ... Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 29 Mar 2022 Status: Closed – Partially addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2019-009-SI-003Risk management associated with changing allright signal procedures for the NGR Number: RO-2019-009-SI-003 Description: RO-2019-009-SI-003:Limitations in Queensland Rail’s application of risk management and change management processes relevant to the introduction of the new generation rollingstock (NGR) increased the risk of a start against signal SPAD (signals passed at danger). Specifically, multiple processes did not effectively consider the risk of station staff at suburban platforms ... Issue owner: Queensland Rail Operation affected: Rail: Passenger - metropolitan	Date, status, type Date: 29 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO 2020 062 SI 01Ballina airport safety review Number: AO 2020 062 SI 01 Description: AO 2020 062 SI 01:The Civil Aviation Safety Authority review of the airspace surrounding Ballina Byron Gateway Airport did not include data for aircraft transiting the airspace without using the airport. Therefore, the risk associated with occurrences such as this one were not specifically considered when assessing the appropriate airspace classification. Issue owner: Civil Aviation Safety Authority Operation affected: Aviation: Airspace management	Date, status, type Date: 25 Mar 2022 Status: Open – Safety action pending Type: Proactive action   Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-05 Fatigue management of train drivers Number: RO-2018-018-SI-05 Description: RO-2018-018-SI-05 :BHP's fatigue management processes required its train drivers to be rostered on 7 12-hour shifts, followed by a 24-hour break and then 7 12-hour shifts, with the roster pattern commencing at a wide variety of times of day. Such roster patterns were conducive to result in cumulative sleep restriction and ... Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Open – Safety action pending Type: Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-04Recovery controls – ATP/ECPB interaction Number: RO-2018-018-SI-04 Description: RO-2018-018-SI-04:The automatic train protection (ATP) and electronically controlled pneumatic braking (ECPB) systems on BHP’s trains could not interface to dump brake pipe pressure if an ECPB emergency or penalty brake application became ineffective in arresting an uncommanded train movement. Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-03Operating instructions – brake pipe emergencies and penalties Number: RO-2018-018-SI-03 Description: RO-2018-018-SI-03:Although operating instructions OI 17-11 (5 April 2017) and then OI 18-72 (3 November 2018) contained a safety-critical action (to apply the automatic brake handle to the pneumatic emergency position), BHP did not clearly communicate the importance and reasons for the safety-critical action to drivers, reducing the potential for the ... Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-02 Task design – brake pipe emergencies and penalties Number: RO-2018-018-SI-02 Description: RO-2018-018-SI-02 :The task of responding to brake pipe emergencies or penalties relied extensively on a driver’s memory, with limited processes in place to facilitate or cross-check a driver’s performance to ensure all safety-critical actions were completed. Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: RO-2018-018-SI-01Risk assessment for a rail-mounted equipment interaction incident Number: RO-2018-018-SI-01 Description: RO-2018-018-SI-01:Although BHP’s risk assessment for a rail-mounted equipment interaction incident identified numerous causes and critical controls for such an incident, it was broad in scope and had limited focus on the causes and critical controls for a train runaway event. In addition, the risk assessment did not include the procedure ... Issue owner: BHP Billiton Iron Ore - Train Operator Operation affected: Rail: Freight	Date, status, type Date: 17 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-053-SI-03Lido airport operational information Number: AO-2018-053-SI-03 Description: AO-2018-053-SI-03:The Lido airport operational information did not include the Australian Aeronautical Information Publication (AIP) advice to fit pitot probe covers at Brisbane Airport (related to significant mud wasp activity), as well as other safety AIP information. Issue owner: Lufthansa Systems Operation affected: Aviation: Other	Date, status, type Date: 16 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-053-SI-05Change and risk management processes Number: AO-2018-053-SI-05 Description: AO-2018-053-SI-05:Malaysia Airlines’ processes for the management of change did not follow recommended industry practices, and its risk and change management processes were not detailed and clear enough to assure: the appropriate level of involvement of subject matter expertise and safety groups that risk controls were implemented and monitored. Issue owner: Malaysia Airlines Operation affected: Aviation: Air transport	Date, status, type Date: 16 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-053-SI-14Guidance about the use of pitot covers Number: AO-2018-053-SI-14 Description: AO-2018-053-SI-14:Malaysia Airlines did not develop and disseminate guidance and procedures about the use of pitot probe covers to flight crews and engineers, and there was limited awareness among those groups of the need for pitot probe covers at Brisbane Airport. Issue owner: Malaysia Airlines Operation affected: Aviation: Maintenance	Date, status, type Date: 16 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-053-SI-02Interim engineering arrangements Number: AO-2018-053-SI-02 Description: AO-2018-053-SI-02:Malaysia Airlines did not clearly specify the division of engineering responsibilities between Malaysia Airlines and Aircraft Maintenance Services Australia engineers at Brisbane, leading to ambiguity with regard to who should conduct the final walk-around portion of the transit check. This risk was increased by the operator commencing and continuing flights ... Issue owner: Malaysia Airlines Operation affected: Aviation: Maintenance	Date, status, type Date: 16 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-053-SI-12Malaysia Airlines inconsistent walk-arounds Number: AO-2018-053-SI-12 Description: AO-2018-053-SI-12:Malaysia Airlines flight crew and engineers did not fully complete the required aircraft inspections. Issue owner: Malaysia Airlines Operation affected: Aviation: Air transport	Date, status, type Date: 16 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-053-SI-18Menzies audits of dispatch coordination tasks Number: AO-2018-053-SI-18 Description: AO-2018-053-SI-18:Menzies Aviation staff did not consistently carry out the required arrival and pre-departure aircraft checks of Malaysia Airlines aircraft, and Menzies Aviation audit processes were not effective at evaluating compliance with these requirements. Issue owner: Menzies Aviation Operation affected: Aviation: Other	Date, status, type Date: 16 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-053-SI-07Aircraft Maintenance Services Australia tool control Number: AO-2018-053-SI-07 Description: AO-2018-053-SI-07:Aircraft Maintenance Services Australia did not have a reliable method to account for tooling and equipment (such as pitot probe covers) prior to aircraft dispatch when providing non-certifying engineering support. Issue owner: Heston MRO Operation affected: Aviation: Maintenance	Date, status, type Date: 16 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action
Issue, description, who it affects Issue: AO-2018-053-SI-01Aircraft Maintenance Services Australia use of pitot covers Number: AO-2018-053-SI-01 Description: AO-2018-053-SI-01:Some Aircraft Maintenance Services Australia (AMSA) engineers extended the use of pitot probe covers (to mitigate the threat of wasp infestation) to operators that did not explicitly require it, including Malaysia Airlines. This increased the likelihood of error associated with the use of pitot probe covers was because AMSA engineers ... Issue owner: Heston MRO [Aircraft Maintenance Services Australia was rebranded as Heston MRO in February 2019.] Operation affected: Aviation: Maintenance	Date, status, type Date: 16 Mar 2022 Status: Closed – Adequately addressed Type: Proactive action