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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
First page Page 1 of 95 Last page Total records: 1899