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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2017-032-SI-01GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Number: AO-2017-032-SI-01
Description: AO-2017-032-SI-01:The ATSB advises that those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3 should note the facts presented in this preliminary report with a view to addressing any risks ...
Who it affects: Those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Issue owner: Operators and maintainers of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Operation affected: Aviation: Air transport
Date, status, type
Date: 13 Apr 2017
Status: Safety action pending
Type: Safety Advisory Notice
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-120-SI-01Emergency oxygen mask and smoke goggles training
Number: AO-2013-120-SI-01
Description: AO-2013-120-SI-01:At the time of the occurrence, the approved QantasLink training did not provide first officers with sufficient familiarity on the use of the oxygen mask and smoke goggles. This likely contributed to the crew's communication difficulties, including with air traffic control.
Who it affects: All QantasLink DHC-8-315 pilots
Issue owner: QantasLink
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Apr 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-005-SI-01Absence of air traffic control procedures and tools for runway changes at Melbourne Airport
Number: AO-2016-005-SI-01
Description: AO-2016-005-SI-01:Airservices Australia did not provide procedures with associated local instructions to Melbourne air traffic controllers regarding how to coordinate runway changes at Melbourne Airport. Furthermore, an absence of system tools increased the risk of the controllers forgetting to coordinate those changes with the Essendon Aerodrome Controller.
Who it affects: Air traffic controllers at Melbourne and Essendon Airports
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 09 Mar 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-009-SI-02 Network rule governing Distant signals
Number: RO-2015-009-SI-02
Description: RO-2015-009-SI-02 :The rule describing the required driver response to a Distant signal at Caution in a two-position signalling system did not fully reflect the signalling system design principles. 
Who it affects: Drivers operating on rail networks using this rule
Issue owner: V/Line
Operation affected: Rail: Operations control
Date, status, type
Date: 12 Dec 2016
Status: Not addressed
Type: Recommendation
  Proactive Action
Issue, description, who it affects
Issue: RO-2015-009-SI-01 Driver training
Number: RO-2015-009-SI-01
Description: RO-2015-009-SI-01 :The training and assessment of the driver did not ensure that he had an adequate understanding of the two-position signalling through Marshall. 
Who it affects: Drivers operating on the V/Line network
Issue owner: V/Line
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 12 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-028-SI-02 Operational rules and procedures
Number: RO-2015-028-SI-02
Description: RO-2015-028-SI-02 :The Queensland Rail network rules, procedures and safety manual provided insufficient guidance to identify the magnitude of the potential hazard from a weather event, or define the response when encountering water that had previously overtopped the track and receded or was pooled against the track formation or ballast.
Who it affects: All rail safety workers conducting work on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-028-SI-01 Hazard identification and assessment by rail traffic crew
Number: RO-2015-028-SI-01
Description: RO-2015-028-SI-01 :The Queensland Rail General Operational Safety Manual (MD-10-107) contained insufficient guidance for rail traffic crews to ensure the timely identification and management of a potential hazard (resulting from a weather event) that might affect the safe progress of the train.
Who it affects: All rail transport operators working rolling stock on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-096 -SI-01Compromised separation recovery training
Number: AO-2014-096 -SI-01
Description: AO-2014-096 -SI-01:Compromised separation recovery training deficiencies existed within the Department of Defence at the time of the occurrence, increasing the risk of inappropriate management of aircraft in close proximity. Note: This safety issue was identified as part of ATSB investigation AO-2012-131 as safety issue AO-2012-131-SI-05 and resulted in the ATSB issuing safety recommendation AO‑2012‑131‑SR‑042 on 2 October 2014 (after the ...
Who it affects: All Department of Defence air traffic controllers
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 05 Dec 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2014-164-SI-01Potential adverse effects of a tip-up canopy opening in-flight
Number: AO-2014-164-SI-01
Description: AO-2014-164-SI-01:In‑flight opening of the tip-up canopy in a number of Van’s Aircraft Inc. models has resulted in varying consequences, including a significant pitch down tendency, increasing the risk of a loss of control. 
Who it affects: Owners of Van’s aircraft fitted with a tip-up canopy
Issue owner: Van’s Aircraft Inc.
Operation affected: Aviation: General aviation
Date, status, type
Date: 25 Nov 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-005-SI-03Open stern offshore support vessels
Number: MO-2015-005-SI-03
Description: MO-2015-005-SI-03:Skandi Pacific’s managers had not adequately assessed the risks associated with working on the aft deck of vessels with open sterns, including consideration of engineering controls to minimise water being shipped on the aft deck.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Partially addressed
Type: Proactive Action
  Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2015-005-SI-02Cargo securing procedures
Number: MO-2015-005-SI-02
Description: MO-2015-005-SI-02:Skandi Pacific’s safety management system (SMS) procedures for cargo securing were inadequate. There was no guidance for methods of securing cargo in adverse weather conditions.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-005-SI-01Cargo handling procedures
Number: MO-2015-005-SI-01
Description: MO-2015-005-SI-01:Skandi Pacific’s safety management system (SMS) procedures for cargo handling in adverse weather conditions were inadequate. Clearly defined weather limits when cargo handling operations could be undertaken and trigger points for suspending operations were not defined, including limits for excessive water on deck.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway (DOF Management)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-04 Towage procedures
Number: MO-2015-002-SI-04
Description: MO-2015-002-SI-04 :Procedures for harbour tugs to meet inbound ships and for their co-ordinated movement in the Fremantle pilotage area were not clearly defined. On 28 February, inadequate co-ordination of the tugs and ineffective communication between Maersk Garonne’s pilot and the tug masters resulted in both tugs, the second one in particular, ...
Who it affects: All those responsible for navigation
Issue owner: Svitzer Australia; Fremantle Ports; Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-03 Contingency planning
Number: MO-2015-002-SI-03
Description: MO-2015-002-SI-03 :Fremantle Pilots’ procedures did not include any contingency plans, including abort points, for risks identified for the pilotage. 
Who it affects: All those responsible for a ship’s safe navigation
Issue owner: Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-02 Passage plan
Number: MO-2015-002-SI-02
Description: MO-2015-002-SI-02 :Fremantle Pilots’ publicly available information to assist ships' masters with preparing a berth to berth passage plan was inadequate and ineffectively implemented. The information provided consisted essentially of a list of waypoints, which was routinely not followed.  
Who it affects: All those responsible for a ship’s safe navigation
Issue owner: Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-01 Bridge resource management
Number: MO-2015-002-SI-01
Description: MO-2015-002-SI-01 :Bridge resource management (BRM) was not effectively implemented on board Maersk Garonne. The ship’s passage plan for the pilotage was inadequate, its bridge team members were not actively engaged in the pilotage and they did not effectively monitor the ship’s passage.
Who it affects: All those responsible for navigation
Issue owner: Maersk Line Ship Management, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-028-SI-01Coordination of activities related to pushback
Number: AO-2016-028-SI-01
Description: AO-2016-028-SI-01:The procedures provided to ground and flight crews by Malaysia Airlines Berhad and the towbarless tractor operator did not provide clear guidance or instruction on coordinating activities related to pushback and, in the case of the tractor operator, were informally replaced by local procedures
Who it affects: Air transport ground handling
Issue owner: Malaysia Airlines Berhad and Menzies Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 12 Sep 2016
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2015-114-SI-01No cockpit annunciation or checklist item for parking brake status
Number: AO-2015-114-SI-01
Description: AO-2015-114-SI-01:The Citation aircraft did not have an annunciator light to show that the parking brake is engaged, and the manufacturer’s before take-off checklist did not include a check to ensure the parking brake is disengaged.
Who it affects: All owners and operators of Cessna Citation aircraft
Issue owner: Textron Aviation (Cessna)
Operation affected: Aviation: General aviation
Date, status, type
Date: 25 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-016-SI-02Passenger Train Marker Light Standards
Number: RO-2014-016-SI-02
Description: RO-2014-016-SI-02:The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.
Who it affects: Rail Operators on Melbourne Metropolitan Rail Network
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Other
Date, status, type
Date: 06 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-016-SI-01Permissive Signalling System
Number: RO-2014-016-SI-01
Description: RO-2014-016-SI-01:The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.
Who it affects: Rail Operators on Melbourne Metropolitan Rail Network
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Other
Date, status, type
Date: 06 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
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