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Safety issues and actions

Issue, description, who it affects	Date, status, type
Issue, description, who it affects Issue: RO-2017-001-SI-01Loading of train Number: RO-2017-001-SI-01 Description: RO-2017-001-SI-01:The train was loaded by approximately 10 per cent more than that recorded on the consist, it is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train. Who it affects: All owners and operators of freight wagons Issue owner: Qube Logistics Operation affected: Rail: Freight	Date, status, type Date: 05 Dec 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2016-160-SI-01Policies and procedures for planning IFR and NVIS flights Number: AO-2016-160-SI-01 Description: AO-2016-160-SI-01:Although the operator’s operations manual stated that emergency medical service flights should be conducted under instrument flight rules (IFR) ‘where practical’, its procedures for night visual flight rules (NVFR) operations using night vision goggles did not clearly state when IFR rather than NVFR should be used.   Who it affects: Operating crew and other occupants on emergency medical service flights Issue owner: CHC Helicopter Australia Operation affected: Aviation: Air transport	Date, status, type Date: 06 Nov 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2018-016-SI-02 Balloon passenger briefing procedures Number: AO-2018-016-SI-02 Description: AO-2018-016-SI-02 :Although the operator had procedures for conducting a verbal safety briefing prior to flight and had safety briefing cards available, its risk controls did not provide assurance that all passengers would understand the required procedures for emergency landings. More specifically: safety briefing cards were not routinely made available to passengers prior ... Who it affects: Crew and passengers on the operator’s flights Issue owner: Go Wild Ballooning Pty Ltd Operation affected: Aviation: General aviation	Date, status, type Date: 30 Oct 2018 Status: Partially addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2018-016-SI-01 Procedures for uploading balloon forecasts Number: AO-2018-016-SI-01 Description: AO-2018-016-SI-01 :The Bureau of Meteorology did not have a procedure to ensure that a recording of the local weather forecast for balloon operations in the Melbourne area was correctly uploaded and accessible to balloon pilots. Who it affects: All balloon operators and pilots in the Melbourne region Issue owner: Bureau of Meteorology Operation affected: Aviation: General aviation	Date, status, type Date: 30 Oct 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: RO-2015-023-SI-01 Rail condition Number: RO-2015-023-SI-01 Description: RO-2015-023-SI-01 :The general condition of the rail on the west track, in the vicinity of the rail fracture, contributed to relatively frequent failures in that area. Who it affects: Users of the affected rail track Issue owner: BHP Billiton Operation affected: Rail: Freight	Date, status, type Date: 12 Oct 2018 Status: Adequately addressed Type: Proactive Action
Issue, description, who it affects Issue: AO-2017-032-SI-01 Lack of inspection method to detect fracture Number: AO-2017-032-SI-01 Description: AO-2017-032-SI-01 :The engine manufacturer did not have specific inspection procedures in the maintenance documents of the propeller shaft to detect a fatigue crack originating from the dowel pin hole. Who it affects: All owners and operators of GE CT7-5A2/-5A3/-9B/-9B2 series engines Issue owner: General Electric (GE) Operation affected: Aviation: Air transport	Date, status, type Date: 10 Oct 2018 Status: Adequately addressed Type: Proactive Action   Proactive Action   Proactive Action   Proactive Action
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