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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2020-007-SI-03Pre-flight risk assessment tool
Number: AO-2020-007-SI-03
Description: AO-2020-007-SI-03:Coulson Aviation did not provide a pre-flight risk assessment for their fire-fighting large air tanker crews. This would provide predefined criteria to ensure consistent and objective decision-making with accepting or rejecting tasks, including factors relating to crew, environment, aircraft and external pressures.
Issue owner: Coulson Aviation
Operation affected: Aviation: General aviation
Date, status, type
Date: 29 Aug 2022
Status: Open – Safety action pending
Type: Proactive action
  Safety recommendation
Issue, description, who it affects
Issue: AO-2020-007-SI-04Windshear warning systems
Number: AO-2020-007-SI-04
Description: AO-2020-007-SI-04:Coulson Aviation fleet of C-130 aircraft were not fitted with a windshear detection system, which increased the risk of a windshear encounter and/or delayed response to a windshear encounter during low level operations.
Issue owner: Coulson Aviation
Operation affected: Aviation: General aviation
Date, status, type
Date: 29 Aug 2022
Status: Open – Safety action pending
Type: Safety recommendation
Issue, description, who it affects
Issue: AO-2020-007-SI-06Windshear procedures and training
Number: AO-2020-007-SI-06
Description: AO-2020-007-SI-06:Coulson Aviation did not include a windshear recovery procedure or scenario in their C‑130 Airplane Flight Manual and annual simulator training respectively, to ensure that crews consistently and correctly responded to a windshear encounter with minimal delay.
Issue owner: Coulson Aviation
Operation affected: Aviation: General aviation
Date, status, type
Date: 29 Aug 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2020-007-SI-05Coulson Aviation’s risk management processes
Number: AO-2020-007-SI-05
Description: AO-2020-007-SI-05:Coulson Aviation's safety risk management processes did not adequately manage the risks associated with large air tanker operations. There were no operational risk assessments conducted or a risk register maintained. Further, as safety incident reports submitted were mainly related to maintenance issues, operational risks were less likely to be considered ...
Issue owner: Coulson Aviation
Operation affected: Aviation: General aviation
Date, status, type
Date: 29 Aug 2022
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: AO-2020-007-SI-07Initial attack certification
Number: AO-2020-007-SI-07
Description: AO-2020-007-SI-07:The New South Wales Rural Fire Service procedures allowed operators to determine when pilots were initial attack capable. However, they intended for the pilot in command to be certified by the United States Department of Agriculture Forest Service certification process.
Issue owner: New South Wales Rural Fire Service
Operation affected: Aviation: General aviation
Date, status, type
Date: 29 Aug 2022
Status: Open – Safety action pending
Type: Safety recommendation
Issue, description, who it affects
Issue: AO-2020-007-SI-02Rural Fire Service aerial supervision requirements
Number: AO-2020-007-SI-02
Description: AO-2020-007-SI-02:The New South Wales Rural Fire Service had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision.
Issue owner: New South Wales Rural Fire Service
Operation affected: Aviation: General aviation
Date, status, type
Date: 29 Aug 2022
Status: Open – Safety action pending
Type: Safety recommendation
Issue, description, who it affects
Issue: AO-2020-007-SI-01Rural Fire Service task rejection management
Number: AO-2020-007-SI-01
Description: AO-2020-007-SI-01:The New South Wales Rural Fire Service did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation.
Issue owner: New South Wales Rural Fire Service
Operation affected: Aviation: General aviation
Date, status, type
Date: 29 Aug 2022
Status: Open – Safety action pending
Type: Safety recommendation
Issue, description, who it affects
Issue: AO-2022-003-SI-01Passenger brace positions
Number: AO-2022-003-SI-01
Description: AO-2022-003-SI-01:The maximum number of passengers that the balloon operator allowed to be carried meant that there was insufficient room in the basket for them to adopt the landing position specified in the operator's procedures to reduce the risk of injury.
Issue owner: Picture This Ballooning
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Aug 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-073-SI-05 Procedure for a rapid disembarkation
Number: AO-2019-073-SI-05
Description: AO-2019-073-SI-05 :Qantas did not have a procedure for a rapid disembarkation, or other similar procedure that would effectively enable rapid deplaning at a slower and more controlled pace than an emergency evacuation. Therefore, the only option for rapid deplaning was an emergency evacuation utilising slides, which unnecessarily increased the risk of ...
Issue owner: Qantas Airways Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 21 Jun 2022
Status: Open – Safety action pending
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2019-073-SI-02 Cabin crew training
Number: AO-2019-073-SI-02
Description: AO-2019-073-SI-02 :Qantas's cabin crew recurrent training did not include any situation whereby a disarmed door would have to be rearmed in an emergency. This increased the likelihood that a door would be opened without the escape slide deployed, reducing the number of available exits.
Issue owner: Qantas Airways Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 21 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2019-073-SI-01 Evacuation commands
Number: AO-2019-073-SI-01
Description: AO-2019-073-SI-01 :Qantas's cabin crew primary evacuation commands did not include phrases such as 'leave everything behind' and 'jump and slide'; instead, these phrases were optional. Consequently, passengers would generally not receive specific guidance until they reached an exit, which would likely slow down the evacuation.
Issue owner: Qantas Airways Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 21 Jun 2022
Status: Open – Safety action pending
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2019-073-SI-03 Passenger safety information
Number: AO-2019-073-SI-03
Description: AO-2019-073-SI-03 :Qantas’s method of briefing passengers provided limited and inconsistent information about how to use the escape slides safely and what to do with cabin baggage in an emergency.
Issue owner: Qantas Airways Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 21 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-01Risk controls associated with pilots identifying fatigue risks associated with insufficient sleep and extended wakefulness
Number: AO-2018-022-SI-01
Description: AO-2018-022-SI-01:The sleep log tool used by the operator contained a coding error and it also pre-loaded sleep periods of future nights by default. This combination of factors reduced the likelihood pilots would identify fatigue risks associated with insufficient sleep and extended wakefulness.
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-02Use of sleep reporting spreadsheet and potential for modification of data input to meet operator’s minimum requirements
Number: AO-2018-022-SI-02
Description: AO-2018-022-SI-02:The operator's fatigue risk management system relied extensively on a sleep reporting spreadsheet (sleep log) that was based on the prior sleep wake model, and the spreadsheet had a transparent rule set that made the recorded data easy to modify to achieve results that met the operator’s minimum sleep and ...
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-04Operator’s circuit and approach procedures for marine pilot transfer operations and criteria for achieving a stabilised approach
Number: AO-2018-022-SI-04
Description: AO-2018-022-SI-04:The operator’s circuit and approach procedures for marine pilot transfer operations did not minimise pilot workload or provide the recommended stabilised approach criteria with mandatory go-around policy. These procedures could allow a combination of conditions that increased the risk of a sustained abnormal flight path and collision with terrain/water.
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-005Operator’s training and assessing procedures for marine pilot transfer operations in degraded visual cueing environments
Number: AO-2018-022-SI-005
Description: AO-2018-022-SI-005:The operator's training and assessing procedures for marine pilot transfer operations did not provide assurance that pilot under supervision experience, helicopter instrumentation, and instructor capability were suitable for line training at night in a degraded visual cueing environment.
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-022-SI-03Configuration of instrument panel for instructor or training/check pilot in degraded visual cueing environments
Number: AO-2018-022-SI-03
Description: AO-2018-022-SI-03:The instrument panels fitted to VH-ZGA and the operator's other EC135 helicopter at Port Hedland were equipped for single-pilot operation under the instrument flight rules. When used for flight training or checking in a degraded visual cueing environment, this configuration has a detrimental effect on the ability of an instructor ...
Issue owner: Heli-Aust Whitsundays Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2019-063-SI-03Organisational change
Number: AO-2019-063-SI-03
Description: AO-2019-063-SI-03:Changes in the operator's key safety post holder positions, safety reporting systems and internal processes reduced effective safety assurance.
Issue owner: Alliance Airlines Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-063-SI-02 Flight crew training
Number: AO-2019-063-SI-02
Description: AO-2019-063-SI-02 :The operator’s training for the Fokker F28-Mk0100 did not prepare pilots for alpha mode activation during critical phases of flight.
Issue owner: Alliance Airlines Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-063-SI-01Safety management reporting system
Number: AO-2019-063-SI-01
Description: AO-2019-063-SI-01:The operator’s safety management reporting system did not enable the effective prioritisation of submitted safety reports.
Issue owner: Alliance Airlines Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Jun 2022
Status: Closed – Adequately addressed
Type: Proactive action
First page Page 1 of 51 Last page Total records: 1003