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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2018-049-SI-01Unclear procedures in Aircraft Maintenance Manual
Number: AO-2018-049-SI-01
Description: AO-2018-049-SI-01:The procedures in the aircraft maintenance manual relating to chip detector debris analysis were written in a way that could cause confusion and error. This probably influenced the actions of the maintenance personnel to release the aircraft to service with a deteriorating bearing.
Issue owner: Pratt & Whitney Canada
Operation affected: Aviation: Maintenance
Date, status, type
Date: 16 Sep 2020
Status: Open – Safety action pending
Type: Safety recommendation
Issue, description, who it affects
Issue: AO-2018-027-SI-01 Balloon visual meteorological conditions
Number: AO-2018-027-SI-01
Description: AO-2018-027-SI-01 :The visual flight rules permitted balloons to arrive and depart in foggy conditions without assurance that sufficient visibility existed to see and avoid obstacles.
Who it affects: All balloon operators of charter flights
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Other
Date, status, type
Date: 11 Aug 2020
Status: Open – Safety action pending
Type: Proactive action
  Safety recommendation
Issue, description, who it affects
Issue: AO-2017-078-SI-01Maintenance practices
Number: AO-2017-078-SI-01
Description: AO-2017-078-SI-01:Cloncurry Air Maintenance had adopted a number of practices, which included using abbreviated inspection checklists, not recording all flight control disturbances and not progressively certifying for every inspection item as the work was completed, which increased the risk of memory-related errors and the omission of tasks.
Who it affects: Cloncurry Air Maintenance
Issue owner: Cloncurry Air Maintenance
Operation affected: Aviation: Maintenance
Date, status, type
Date: 21 Jul 2020
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2017-066-SI-02Inspection period for blade cracking
Number: AO-2017-066-SI-02
Description: AO-2017-066-SI-02:The scheduled inspections recommended by Rolls-Royce to detect cracking in Trent 700 fan blades, were insufficient to detect early onset fatigue cracks in the membrane to panel bond before those cracks could progress to failure.
Who it affects: Air transport operators whose aircraft are fitted with Trent 700 engines.
Issue owner: Rolls-Royce plc
Operation affected: Aviation: Air transport
Date, status, type
Date: 30 Jun 2020
Status: Closed – Adequately addressed
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2017-066-SI-01Fatigue cracking of Trent 700 fan blades
Number: AO-2017-066-SI-01
Description: AO-2017-066-SI-01:The Trent 700 blade manufacturing process produced a variation in internal membrane-to-panel acute corner geometry that, in combination with the inherent high level of blade panel stress, could lead to increased localised stresses in those corner areas and the initiation and propagation of fatigue cracking.
Who it affects: Air transport operators whose aircraft are fitted with Trent 700 engines.
Issue owner: Rolls-Royce plc
Operation affected: Aviation: Air transport
Date, status, type
Date: 30 Jun 2020
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-014-SI-03Guidance on vehicle-assisted deflation risks
Number: AO-2019-014-SI-03
Description: AO-2019-014-SI-03:The Civil Aviation Safety Authority provided no guidance for operators concerning the risks associated with vehicle‑assisted deflation.
Who it affects: Commercial Balloon operators that use a vehicle to assist during deflation
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Other
Date, status, type
Date: 29 Jun 2020
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-014-SI-01Risk management processes
Number: AO-2019-014-SI-01
Description: AO-2019-014-SI-01:Picture This Ballooning's safety risk management processes and practices were not sufficient to facilitate the identification of key operational risks associated with vehicle-assisted deflation.
Who it affects: Commercial Balloon operators that use a vehicle to assist during deflation
Issue owner: Picture This Ballooning
Operation affected: Aviation: Other
Date, status, type
Date: 29 Jun 2020
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-014-SI-02Vehicle-assisted deflation procedures
Number: AO-2019-014-SI-02
Description: AO-2019-014-SI-02:Picture This Ballooning did not have any procedures for conducting vehicle-assisted deflation.
Who it affects: Commercial Balloon operators that use a vehicle to assist during deflation
Issue owner: Picture This Ballooning
Operation affected: Aviation: Other
Date, status, type
Date: 29 Jun 2020
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-019-SI-01 Pilatus PC-12 trim and flap interrupt switches
Number: AO-2019-019-SI-01
Description: AO-2019-019-SI-01 :The similarities between the Trim Interrupt and Flap Interrupt switches and the proximal location of the two switches unnecessarily increased the risk of mis-selection and contributed to the excessive out-of-trim condition.
Who it affects: Operators and pilots of PC-12 aircraft
Issue owner: Pilatus Aircraft Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 13 May 2020
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-089-SI-01 Cicaré S.A. CH-7T/B/BT service bulletin
Number: AO-2015-089-SI-01
Description: AO-2015-089-SI-01 :The Cicaré 7T/B/BT mandatory service bulletin (BSC007) for the general stabiliser support assembly provided limited guidance for disassembly of the manufactured component and did not stipulate a compliance period within which to perform the inspection nor provide consideration for repeat inspections. This potentially reduced the opportunity to detect the presence ...
Who it affects: All owners and operators of Cicaré CH7T/B/BT helicopters
Issue owner: Cicaré S.A.
Operation affected: Aviation: General aviation
Date, status, type
Date: 20 Dec 2019
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2017-098-SI-01Passenger oxygen mask instructions
Number: AO-2017-098-SI-01
Description: AO-2017-098-SI-01:The pre-flight safety briefing and safety information card did not include a clear instruction on how to activate the flow of oxygen from the passenger oxygen masks and that the bag may not inflate when oxygen is flowing. This resulted in some passengers not understanding whether or not there was ...
Who it affects: Airline passengers
Issue owner: AirAsia Indonesia
Operation affected: Aviation: Air transport
Date, status, type
Date: 26 Nov 2019
Status: Closed – Adequately addressed
Type: Safety recommendation
Issue, description, who it affects
Issue: AO 2017-013-SI-01Air display approval and oversight
Number: AO 2017-013-SI-01
Description: AO 2017-013-SI-01:The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors: While the Air Display Manual provided guidance to organisers conducting an air display, it did not inherently provide the processes and tools needed for CASA to approve ...
Who it affects: Air displays: Organisers and participants in air displays
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Other
Date, status, type
Date: 19 Nov 2019
Status: Open – Safety action pending
Type: Proactive action
  Safety recommendation
Issue, description, who it affects
Issue: AO-2018-007-SI-01Advantage 70 engine modification
Number: AO-2018-007-SI-01
Description: AO-2018-007-SI-01:There were a total of 16 engine malfunction events globally over a 4-year period attributed to modification of the Advantage 70™ engine. The modification increased the engine outer duct gas path temperature, which led to distortion and liberation of the outer transition duct segments.
Who it affects: All operators of Airbus A330 aircraft fitted with Pratt & Whitney PW4170 engines or Advantage 70™ engine modification.
Issue owner: Pratt & Whitney
Operation affected: Aviation: Air transport
Date, status, type
Date: 06 Nov 2019
Status: Safety action pending
Type: Proactive Action
  Recommendation
  Recommendation
Issue, description, who it affects
Issue: AO-2018-025-SI-01CASA ALA guidance on runway overrun areas
Number: AO-2018-025-SI-01
Description: AO-2018-025-SI-01:The Civil Aviation Advisory Publication for Aeroplane Landing Areas (92-1(1)) did not have guidance for the inclusion of a safe runway overrun area.
Who it affects: All owners and users of ALAs
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 22 Oct 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2017-005-SI-08Regulatory surveillance – scoping of surveillance events
Number: AO-2017-005-SI-08
Description: AO-2017-005-SI-08:The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or ...
Who it affects: All operators.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: AO-2017-005-SI-07 Requirements for briefing the brace position in small aircraft
Number: AO-2017-005-SI-07
Description: AO-2017-005-SI-07 :There was no requirement for operators of passenger transport flights in aircraft with six or less seats to provide passengers with a verbal briefing, or written briefing material, on the brace position for an emergency landing or ditching, even for aircraft without upper torso restraints fitted to all passenger seats.
Who it affects: All aircraft owners, operators, pilots and passengers of small aeroplanes.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: Safety action pending
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2017-005-SI-06 Requirements for upper torso restraints in small aircraft
Number: AO-2017-005-SI-06
Description: AO-2017-005-SI-06 :Upper torso restraints (UTRs) were not required for all passenger seats for small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992, including for passenger transport operations. Although options for retrofitting UTRs are available for many models of small aircraft, many of these aircraft manufactured before the applicable ...
Who it affects: All aircraft owners, operators, pilots and passengers of small aircraft without upper torso restraints for all passenger seats.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: Not addressed
Type: Safety advisory notice
  Recommendation
Issue, description, who it affects
Issue: AO-2017-005-SI-05Operator’s processes for reviewing its operations
Number: AO-2017-005-SI-05
Description: AO-2017-005-SI-05:There were a significant number and variety of problems associated with the operator’s activities that increased safety risk, and the operator’s chief pilot held all the key positions within the operator’s organisation and conducted most of the operator’s flights. Overall, there were no effective mechanisms in place to regularly and ...
Who it affects: The operator’s pilots and passengers.
Issue owner: Wyndham Aviation Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: No longer relevant
Issue, description, who it affects
Issue: AO-2017-005-SI-04Operator’s conduct of near-aerobatic manoeuvres during charter flights
Number: AO-2017-005-SI-04
Description: AO-2017-005-SI-04:The operator’s pilots routinely conducted near-aerobatic manoeuvres during passenger charter flights. However, procedures for these manoeuvres were not specified in the operator’s Operations Manual, and there were limited controls in place to manage the risk of these manoeuvres.
Who it affects: The operator’s pilots and passengers.
Issue owner: Wyndham Aviation Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: No longer relevant
Issue, description, who it affects
Issue: AO-2017-005-SI-03Operator’s practices for securing baggage and other cargo
Number: AO-2017-005-SI-03
Description: AO-2017-005-SI-03:Although the operator’s procedures required that baggage and cargo be secured during flight, this procedure was routinely not followed, and the aircraft were not equipped with cargo nets or other means for securing loads in the baggage compartment.
Who it affects: The operator’s pilots and passengers.
Issue owner: Wyndham Aviation Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 17 Oct 2019
Status: No longer relevant
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