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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2020-041-S1-01Maintenance Publications
Number: AO-2020-041-S1-01
Description: AO-2020-041-S1-01:While the manufacturer's instructions for the zonal inspections detailed that installation blankets could be removed 'as necessary', they did not reference the insulation blanket installation procedure. This resulted in insulation blankets not being secured to the structure.
Issue owner: Fokker Services
Operation affected: Aviation: Maintenance
Date, status, type
Date: 22 Jan 2021
Status: Open – Safety action pending
Type: Proactive action
  Proactive action
  Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2016-155-SI-01 Compressor turbine blade failure
Number: AO-2016-155-SI-01
Description: AO-2016-155-SI-01 :Pratt & Whitney Canada (PWC) PT6A-114A engines fitted with compressor turbine vane rings that have been repaired in accordance with the United States Federal Aviation Administration‑approved scheme STI 72-50-254 have a significantly increased likelihood of CMSX-6 compressor turbine blade fracture and subsequent failure of the engine compared to those engines ...
Issue owner: United States Federal Aviation Administration
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Dec 2020
Status: Open – Safety action pending
Type: Proactive action
  Proactive action
  Proactive action
  Proactive action
  Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2019-055-SI-02 Runway verification cues
Number: AO-2019-055-SI-02
Description: AO-2019-055-SI-02 :Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.
Issue owner: Virgin Australia Airlines
Operation affected: Aviation: Air transport
Date, status, type
Date: 11 Dec 2020
Status: Open – Safety action pending
Issue, description, who it affects
Issue: AO-2019-055-SI-01 Timing of 'before take-off' procedure
Number: AO-2019-055-SI-01
Description: AO-2019-055-SI-01 :Virgin Australia Airlines did not require ATR flight crews to complete the Before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying ...
Issue owner: Virgin Australia Airlines
Operation affected: Aviation: Air transport
Date, status, type
Date: 11 Dec 2020
Status: No longer relevant
Issue, description, who it affects
Issue: AO-2018-006-SI-02Pilot’s operating handbook
Number: AO-2018-006-SI-02
Description: AO-2018-006-SI-02:The Robinson R44 pilot’s operating handbook low rotor RPM recovery procedure did not include reference to the minimum power airspeed for the helicopter as a consideration, which may assist a pilot to recover from a low rotor RPM condition.
Issue owner: Robinson Helicopter Company
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Oct 2020
Status: Open – Safety action pending
Type: Proactive action
  Safety recommendation
Issue, description, who it affects
Issue: AO-2018-006-SI-01Passenger scales
Number: AO-2018-006-SI-01
Description: AO-2018-006-SI-01:Professional Helicopter Services did not have a calibration schedule for their passenger scales, which were under-reading. This increased the risk of their helicopters not achieving their expected take-off performance.
Issue owner: Professional Helicopter Services
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Oct 2020
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-032-SI-03Inhibition of safety alerts for combined air traffic control roles
Number: AO-2018-032-SI-03
Description: AO-2018-032-SI-03:Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combined roles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation ...
Who it affects: Tower controllers at Perth Airport
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 01 Oct 2020
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2018-032-SI-02Location and design of taxiway J2 at Perth Airport
Number: AO-2018-032-SI-02
Description: AO-2018-032-SI-02:The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient ...
Who it affects: All flight crew and operators of jet aircraft using runway 03 at Perth Airport
Issue owner: Perth Airport Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 01 Oct 2020
Status: Closed – Adequately addressed
Type: Proactive action
  Proactive action
Issue, description, who it affects
Issue: AO-2018-032-SI-01Operator guidance for flight crew briefing of aerodrome hot spots
Number: AO-2018-032-SI-01
Description: AO-2018-032-SI-01:Although Qantas provided detailed guidance to flight crews about the content of departure and approach briefings, it did not specifically require aerodrome hot spots to be briefed.
Who it affects: All of the operator’s flight crew
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 01 Oct 2020
Status: Closed – Adequately addressed
Type: Proactive action
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: Closed – Adequately addressed
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
First page Page 1 of 47 Last page Total records: 933