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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2014-032-SI-08Undetected horizontal stabiliser damage in world fleet
Number: AO-2014-032-SI-08
Description: AO-2014-032-SI-08:As a legacy of there being no inspection specific to an in-flight pitch disconnect, there is potential for other ATR aircraft to have sustained an in-flight pitch disconnect in the past and be operating with undetected horizontal stabiliser damage.
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status:
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-032-SI-07Maintenance requirements following an in-flight pitch disconnect
Number: AO-2014-032-SI-07
Description: AO-2014-032-SI-07:The aircraft manufacturer, ATR, did not provide a maintenance inspection to specifically assess the effect of an in-flight pitch disconnect on the structural integrity of the horizontal stabilisers. As a result, if an in-flight pitch disconnect occurred, the aircraft may not be inspected at a level commensurate with the criticality ...
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-032-SI-06No consideration of dual control inputs on aircraft response in the design standard
Number: AO-2014-032-SI-06
Description: AO-2014-032-SI-06:Although the design standard for the aircraft (JAR-25) required the control system to be of sufficient strength to withstand dual control inputs, it did not require consideration of the effect that dual control inputs may have on control of the aircraft. Similarly, the current design standard (CS-25) does not address ...
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: European Aviation Safety Agency (EASA)
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2014-032-SI-05No consideration of transient control loads in the design standard
Number: AO-2014-032-SI-05
Description: AO-2014-032-SI-05:The design standard for large transport aircraft, Joint Aviation Requirements - Part 25 (JAR-25), did not require that the demonstrated potential for flexibility in the control system to develop transient dynamic loads, be considered during certification. Similarly, the current certification standard for Large Aeroplanes (CS-25) does not address this issue.
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: European Aviation Safety Agency (EASA)
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-032-SI-04Effect of dual control inputs on elevator response
Number: AO-2014-032-SI-04
Description: AO-2014-032-SI-04:Flexibility in the ATR 72’s pitch control system between the control columns results in a change in the aircraft’s longitudinal handling qualities and control dynamics when dual control inputs are made. This could result in an aircraft-pilot coupling event where flight crew may find it difficult to control the aircraft.
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2014-032-SI-03Reduced flight control tactile feedback
Number: AO-2014-032-SI-03
Description: AO-2014-032-SI-03:The design of the ATR 72 pitch control system resulted in limited tactile feedback between the left and right control columns, reducing the ability of one pilot to detect that the other pilot is making control inputs. In addition, there were no visual or auditory systems to indicate dual control ...
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 May 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2016-166-SI-04En route supplement guidance to flight crews
Number: AO-2016-166-SI-04
Description: AO-2016-166-SI-04:The En Route Supplement Australia (ERSA) did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.
Who it affects: Pilots operating into Darwin airport
Issue owner: Darwin International Airport
Operation affected: Aviation: Airports
Date, status, type
Date: 15 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-166-SI-03Operator guidance to flight crews
Number: AO-2016-166-SI-03
Description: AO-2016-166-SI-03:Virgin Australia did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.
Who it affects: Virgin Australia Airlines flight crews operating into Darwin airport
Issue owner: Virgin Australia Airlines
Operation affected: Aviation: Air transport
Date, status, type
Date: 15 May 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-166-SI-02Limited visual cues for approach at Darwin runway 11/29
Number: AO-2016-166-SI-02
Description: AO-2016-166-SI-02:The absence of centreline lighting and the 60-m width of runway 11/29 at Darwin result in very limited visual cues for maintaining runway alignment during night landings in reduced visibility.
Who it affects: Pilots operating into Darwin airport
Issue owner: Darwin International Airport
Operation affected: Aviation: Airports
Date, status, type
Date: 15 May 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2016-166-SI-01Standards for installation of runway centreline lighting on wider runways
Number: AO-2016-166-SI-01
Description: AO-2016-166-SI-01:Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions. The installation of centreline lighting on wider category I runways is recommended but not mandated by the International Civil Aviation Organization Annex 14.
Who it affects: Operators using runways wider than 50 m without centreline lighting
Issue owner: International Civil Aviation Organization
Operation affected: Aviation: Airports
Date, status, type
Date: 15 May 2019
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2015-107-SI-02NAV ADR DISAGREE procedure
Number: AO-2015-107-SI-02
Description: AO-2015-107-SI-02:A NAV ADR DISAGREE alert can be triggered by either an airspeed discrepancy, or angle of attack discrepancy. The alert does not identify which, and the associated procedure may lead flight crews to incorrectly diagnosing the source of the alert when the airspeed is erroneous for a short period and ...
Who it affects: Operators of Airbus A320 aircraft
Issue owner: Airbus
Operation affected: Aviation: Air transport
Date, status, type
Date: 04 Apr 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2015-107-SI-01Priority of NAV ADR DISAGREE alert
Number: AO-2015-107-SI-01
Description: AO-2015-107-SI-01:Although the NAV ADR DISAGREE had more immediate safety implications relating to unreliable airspeed, the ECAM alert priority logic placed this alert below the engine-related faults. As a result, the NAV ADR DISAGREE alert was not immediately visible to the flight crew due to the limited space available on the ...
Who it affects: Operators of Airbus A320 aircraft
Issue owner: Airbus
Operation affected: Aviation: Air transport
Date, status, type
Date: 04 Apr 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2017-044-SI-02Re-evaluating hold speeds for a change in altitude
Number: AO-2017-044-SI-02
Description: AO-2017-044-SI-02:The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude.
Who it affects: Qantas Airways Boeing 747 flight crew
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2017-044-SI-01Stall prevention and recovery at high altitudes
Number: AO-2017-044-SI-01
Description: AO-2017-044-SI-01:The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle.
Who it affects: Qantas Airways Boeing 747 flight crew
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Mar 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AR-2017-011-SI-01 Wake turbulence occurrences at Sydney Airport
Number: AR-2017-011-SI-01
Description: AR-2017-011-SI-01 :Given the parallel runway configuration, there was a disproportionate rate of reported wake turbulence occurrences for aircraft arriving at Sydney Airport compared to other major Australian airports in the years 2012 to 2016. Wake turbulence occurrences at Sydney Airport were found to be primarily associated with three factors: arrival densities of ...
Who it affects: Aircraft arriving at Sydney Airport
Issue owner: Airservices Australia
Operation affected: Aviation: Air transport
Date, status, type
Date: 15 Feb 2019
Status: Safety action pending
Type: Recommendation
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: 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
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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
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