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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2015-046-SI-05In-flight landing distance safety margin may be inadequate
Number: AO-2015-046-SI-05
Description: AO-2015-046-SI-05:Civil Aviation Order 20.7.1B stipulated that a 1.15 (15 per cent) safety margin was to be applied to the actual landing distance for jet-engine aircraft with a maximum take-off weight greater than 5,700 kg. This safety margin may be inadequate under certain runway conditions, which increases the risk of a ...
Who it affects: Civil Aviation Safety Authority
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Sep 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-046-SI-03Cross-checking environmental information and landing performance
Number: AO-2015-046-SI-03
Description: AO-2015-046-SI-03:Virgin Australia Airlines/Virgin Australia International did not have a policy requiring crews to independently cross-check environmental information and landing performance calculations in-flight, removing an opportunity to detect crew errors.
Who it affects: Virgin Australia Airlines/Virgin Australia International crews
Issue owner: Virgin Australia Airlines/Virgin Australia International
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Sep 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-046-SI-02Regulatory direction regarding damp runways
Number: AO-2015-046-SI-02
Description: AO-2015-046-SI-02:There was no regulatory direction from the Civil Aviation Safety Authority on how a damp runway was to be considered for aircraft landing performance.
Who it affects: Operators and pilots of aircraft where landing performance data is not available for damp runway surface conditions
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Sep 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-046-SI-01Change in ‘damp’ definition for performance purposes
Number: AO-2015-046-SI-01
Description: AO-2015-046-SI-01:Several months prior to the incident, Virgin Australia Airlines/Virgin Australia International changed their policy on calculating landing performance for damp runways from referencing a wet runway to a dry runway.
Who it affects: Virgin Australia Airlines/Virgin Australia International crews
Issue owner: Virgin Australia Airlines/Virgin Australia International
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Sep 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-084-SI-01Hazard associated with the inability to separate aircraft below the appropriate lowest safe altitude at night
Number: AO-2015-084-SI-01
Description: AO-2015-084-SI-01:The hazard associated with the inability to separate aircraft that are below the appropriate lowest safe altitude at night was identified but not adequately mitigated. This resulted in a situation where, in the event of a simultaneous go-around at night during land and hold short operations at Melbourne Airport, there ...
Who it affects: Air traffic controllers employed in the Melbourne Tower
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 06 Aug 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-078-SI-01Air Operator Certificate holder fuel policy requirements
Number: AO-2016-078-SI-01
Description: AO-2016-078-SI-01:The current legislation does not require commercial operators of aircraft not greater than 5,700 kg maximum take-off weight to provide instructions and procedures for crosschecking the quantity of fuel on board before and/or during flight. This increases the risk that operators in this category will not implement effective fuel policies ...
Who it affects: Air Operator Certificate holders
Issue owner: Civil Aviation Safety Authority (CASA)
Operation affected: Aviation: Air transport
Date, status, type
Date: 02 Aug 2018
Status: Safety action pending
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2016-004-SI-01Preventative maintenance systems
Number: RO-2016-004-SI-01
Description: RO-2016-004-SI-01:The presence of the earlier design of yoke on wagon NGKF 35898X was not detected during preventative maintenance activities.
Who it affects: Pacific National
Issue owner: Pacific National
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Jun 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2017-003-SI-01Processes for the monitoring of the exciter unit insulation resistance
Number: MO-2017-003-SI-01
Description: MO-2017-003-SI-01:The processes for monitoring the condition of the brushless exciter units’ electrical insulation were ineffective in detecting deterioration prior to unit failure.
Who it affects: Those responsible for maintaining Azipods
Issue owner: Norwegian Cruise Line Holdings Ltd (NCLH) and ABB Industry Oy (ABB)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 May 2018
Status: Safety action pending
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: RO-2016-002-SI-07Train radio functionality
Number: RO-2016-002-SI-07
Description: RO-2016-002-SI-07:The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to override an initial lower-priority call.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-06Standard for derailment risk on small-radius curves
Number: RO-2016-002-SI-06
Description: RO-2016-002-SI-06:There was no network standard that directly dealt with increased derailment risk on small-radius curves.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-05Management of wide gauge defect
Number: RO-2016-002-SI-05
Description: RO-2016-002-SI-05:Track geometry through the Rushall curve was not managed in accordance with Metro Trains Melbourne (MTM) network standards. A wide-gauge ‘A’ fault was not rectified in the field despite being closed-out on the asset management system.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-02Standard for angular discontinuity at mechanical joints
Number: RO-2016-002-SI-02
Description: RO-2016-002-SI-02:The network’s track geometry standard did not include any specific requirement to limit a localised lateral angular discontinuity in rail line at a mechanical joint.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-04Track geometry standards
Number: RO-2016-002-SI-04
Description: RO-2016-002-SI-04:The network’s track geometry standards were probably unsuitable for small-radius Broad-Gauge curves. A combination of track geometry irregularities had increased the probability of flange-climb at several locations on the small-radius Rushall curve.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-03Location of rail lubricators
Number: RO-2016-002-SI-03
Description: RO-2016-002-SI-03:The positioning of the rail lubricators at this and several other locations on the network was not consistent with Metro Trains Melbourne (MTM) guidelines and probably reduced their effectiveness.
Who it affects: Rail: Passenger – metropolitan and regional
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2016-002-SI-01Rail lubricator maintenance
Number: RO-2016-002-SI-01
Description: RO-2016-002-SI-01:The maintenance of rail lubricators had become less effective in the months leading up to the derailment. This work was being transferred from contractors to internal Metro Trains Melbourne (MTM) staff and the transition was not adequately managed.
Who it affects: Owners and operators of passenger rail services in Victoria
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 16 May 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2018-022-SAN-001Helicopter underwater escape training
Number: AO-2018-022-SAN-001
Description: AO-2018-022-SAN-001:The Australian Transport Safety Bureau advises helicopter operators involved in overwater operations of the importance of undertaking regular HUET (helicopter underwater escape training) for all crew and regular passengers to increase their survivability in the event of an in-water accident or ditching. Safety Advisory Notice for all helicopter operators engaged in ...
Who it affects: All overwater helicopter operators
Issue owner: All overwater helicopter operators
Operation affected: Aviation: Other
Date, status, type
Date: 03 May 2018
Status: Safety action pending
Issue, description, who it affects
Issue: AI-2013-102-SI-01The use of risk management principles when considering an application under the Airports (Protected Airspace) Regulations
Number: AI-2013-102-SI-01
Description: AI-2013-102-SI-01:The Department of Infrastructure, Regional Development and Cities adopted a prescriptive approach to the Hume City Council building application within the obstacle limitation area of Essendon Airport, which was in accordance with the process prescribed under the Airports (Protection of Airspace) Regulations 1996, but did not require the application of ...
Who it affects: Airports managing protected airspace associated with their runways
Issue owner: The Department of Infrastructure, Regional Development and Cities
Operation affected: Aviation: Airspace management
Date, status, type
Date: 03 May 2018
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-105-SI-01Autopilot advice, limitations cautions and warnings (written and audible)
Number: AO-2015-105-SI-01
Description: AO-2015-105-SI-01:The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.
Who it affects: Aircraft owners and operators of aircraft fitted with the Garmin G1000 avionics system and GFC700 autopilot.
Issue owner: Cessna Aircraft Company (Textron)
Operation affected: Aviation: General aviation
Date, status, type
Date: 17 Apr 2018
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2015-105-SI-02Autopilot advice, limitations cautions and warnings (written and audible)
Number: AO-2015-105-SI-02
Description: AO-2015-105-SI-02:The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.
Who it affects: Aircraft owners and operators of aircraft fitted with the Garmin G1000 avionics system and GFC700 autopilot.
Issue owner: Garmin
Operation affected: Aviation: General aviation
Date, status, type
Date: 17 Apr 2018
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2015-066-SI-01Elevated risk from non-precision approach with low-level circling and non-stabilised approach procedure
Number: AO-2015-066-SI-01
Description: AO-2015-066-SI-01:The operator commenced regular public transport operations into Kosrae with the only instrument approach available for use being an offset procedure based on a non-precision navigation aid. The risk associated with this type of approach was amplified due to the need to use a 'dive and drive' style technique instead ...
Who it affects: Nauru Airlines
Issue owner: Nauru Airlines
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Mar 2018
Status: Adequately addressed
Type: Proactive Action
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