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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: RO-2015-028-SI-01 Hazard identification and assessment by rail traffic crew
Number: RO-2015-028-SI-01
Description: RO-2015-028-SI-01 :The Queensland Rail General Operational Safety Manual (MD-10-107) contained insufficient guidance for rail traffic crews to ensure the timely identification and management of a potential hazard (resulting from a weather event) that might affect the safe progress of the train.
Who it affects: All rail transport operators working rolling stock on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-096 -SI-01Compromised separation recovery training
Number: AO-2014-096 -SI-01
Description: AO-2014-096 -SI-01:Compromised separation recovery training deficiencies existed within the Department of Defence at the time of the occurrence, increasing the risk of inappropriate management of aircraft in close proximity. Note: This safety issue was identified as part of ATSB investigation AO-2012-131 as safety issue AO-2012-131-SI-05 and resulted in the ATSB issuing safety recommendation AO‑2012‑131‑SR‑042 on 2 October 2014 (after the ...
Who it affects: All Department of Defence air traffic controllers
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 05 Dec 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2014-164-SI-01Potential adverse effects of a tip-up canopy opening in-flight
Number: AO-2014-164-SI-01
Description: AO-2014-164-SI-01:In‑flight opening of the tip-up canopy in a number of Van’s Aircraft Inc. models has resulted in varying consequences, including a significant pitch down tendency, increasing the risk of a loss of control. 
Who it affects: Owners of Van’s aircraft fitted with a tip-up canopy
Issue owner: Van’s Aircraft Inc.
Operation affected: Aviation: General aviation
Date, status, type
Date: 25 Nov 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-028-SI-01Coordination of activities related to pushback
Number: AO-2016-028-SI-01
Description: AO-2016-028-SI-01:The procedures provided to ground and flight crews by Malaysia Airlines Berhad and the towbarless tractor operator did not provide clear guidance or instruction on coordinating activities related to pushback and, in the case of the tractor operator, were informally replaced by local procedures
Who it affects: Air transport ground handling
Issue owner: Malaysia Airlines Berhad and Menzies Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 12 Sep 2016
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2015-114-SI-01No cockpit annunciation or checklist item for parking brake status
Number: AO-2015-114-SI-01
Description: AO-2015-114-SI-01:The Citation aircraft did not have an annunciator light to show that the parking brake is engaged, and the manufacturer’s before take-off checklist did not include a check to ensure the parking brake is disengaged.
Who it affects: All owners and operators of Cessna Citation aircraft
Issue owner: Textron Aviation (Cessna)
Operation affected: Aviation: General aviation
Date, status, type
Date: 25 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2014-032-SI-01Inadvertent activation of the elevator control system - pitch uncoupling mechanism
Number: AO-2014-032-SI-01
Description: AO-2014-032-SI-01:Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 15 Jun 2016
Status:
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-100-SI-02Alerting function of special weather reports (SPECI) is not met by the automatic broadcast services
Number: AO-2013-100-SI-02
Description: AO-2013-100-SI-02:The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.
Who it affects: All pilots operating into non-major airports accessing an automatic broadcast service
Issue owner: Airservices Australia in consultation with the Bureau of Meteorology
Operation affected: Aviation: Air transport
Date, status, type
Date: 31 May 2016
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2013-100-SI-01Limited provision of flight information service for some non major airports
Number: AO-2013-100-SI-01
Description: AO-2013-100-SI-01:For many non‑major airports in Australia, flight crews of arriving aircraft can access current weather information using an Automatic Weather Information Service via very high frequency radio, which has range limitations. Where this service is available, air traffic services will generally not alert pilots to significant deteriorations in current weather ...
Who it affects: All pilots operating into non-major airports accessing an Automatic Weather Information Service
Issue owner: Airservices Australia in consultation with the Bureau of Meteorology
Operation affected: Aviation: Air transport
Date, status, type
Date: 31 May 2016
Status:
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-074-SI-02Compromised separation recovery training
Number: AO-2014-074-SI-02
Description: AO-2014-074-SI-02:Airservices Australia had not provided en route air traffic controllers with effective simulator-based refresher training in identifying and responding to compromised separation scenarios, at intervals appropriate to ensure that controllers maintained effective practical skills.
Who it affects: All Airservices Australia en route air traffic controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 13 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-074-SI-01Air traffic control shift management practices
Number: AO-2014-074-SI-01
Description: AO-2014-074-SI-01:The utilisation of  shift sharing practices for the Tops controllers resulted in them sustaining a higher workload over extended periods without a break, during a time of day known to reduce performance capability.
Who it affects: All Airservices Australia air traffic controllers operating on night shifts
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 13 May 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-212-SI-01Identification of pitot probe in the trouble shooting manual
Number: AO-2013-212-SI-01
Description: AO-2013-212-SI-01:The relevant tasks in the trouble shooting manual did not specifically identify the pitot probe as a potential source of airspeed indication failure.
Who it affects: Maintenance engineers
Issue owner: Airbus
Operation affected: Aviation: Air transport
Date, status, type
Date: 06 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-163-SI-01Flight manual requirements for amateur-built experimental aircraft
Number: AO-2014-163-SI-01
Description: AO-2014-163-SI-01:The Civil Aviation Safety Authority did not require builders of amateur‑built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. Without a flight manual the builder, other pilots and subsequent owners do not have reference to operational and performance data necessary to safely operate ...
Who it affects: Operators of amateur-built experimental aircraft
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 14 Apr 2016
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2015-028-SI-01Inadequate inspection procedures
Number: AO-2015-028-SI-01
Description: AO-2015-028-SI-01:The maintenance program for the aircraft’s landing gear did not adequately provide for the detection of corrosion and cracking in the yoke lug bore.
Who it affects: All owners and operators of Fairchild Swearingen Metro and Merlin aircraft
Issue owner: M7 Aerospace (Elbit Systems of America)
Operation affected: Aviation: Maintenance
Date, status, type
Date: 22 Mar 2016
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AR-2013-107-SI-01Through-bolt failures in Jabiru engines
Number: AR-2013-107-SI-01
Description: AR-2013-107-SI-01:Thicker 7/16 inch diameter through-bolts, fitted to newer Jabiru engines and some retro-fitted engines, have had limited service to date to confirm early indications that they reduce this risk. Retro-fitting engines with thicker through-bolts has only been recommended for aircraft involved in flight training by JSB031 issue 3. Most light ...
Who it affects: Owners and operators of aircraft powered by Jabiru engines
Issue owner: Jabiru Aircraft Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Mar 2016
Status: Safety action pending
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: AO-2013-187-SI-02Removal of wings to complete service bulletin actions
Number: AO-2013-187-SI-02
Description: AO-2013-187-SI-02:Although wing removal was necessary to provide adequate access for effective visual and magnetic particle inspections of M18 wing attachment fittings, the aircraft manufacturer’s service bulletin E/02.170/2000 allowed the wings to remain attached during these inspections.
Who it affects: Maintainers of M18 aircraft completing CASA AD/PZL/5 and PZL Mielec service bulletin E/02.170/2000
Issue owner: PZL Mielec
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-01M18 Dromader airframe life factoring
Number: AO-2013-187-SI-01
Description: AO-2013-187-SI-01:Operators of some Australian M18 Dromaders, particularly those fitted with turbine engines and enlarged hoppers and those operating under Australian supplemental type certificate (STC) SVA521, have probably conducted flights at weights for which airframe life factoring was required but not applied. The result is that some of these aircraft could ...
Who it affects: Operators of PZL M18 aircraft
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Safety Advisory Notice
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-04Spectrum of flight loads
Number: AO-2013-187-SI-04
Description: AO-2013-187-SI-04:Operation of M18 aircraft with a more severe flight load spectrum results in greater fatigue damage than anticipated by the manufacturer when determining the service life of the M18. If not properly accounted for, the existing service life limit, and particular inspection intervals, may not provide the intended level of ...
Who it affects: All operators of M18 aircraft
Issue owner: Operators of M18 aircraft
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-03Use of eddy current inspection for airworthiness directive AD/PZL/5
Number: AO-2013-187-SI-03
Description: AO-2013-187-SI-03:The eddy current inspection used on VH-TZJ, and other M18 aircraft, had not been approved by the Civil Aviation Safety Authority as an alternate means of compliance to airworthiness directive AD/PZL/5. This exposed those aircraft to an inspection method that was potentially ineffective at detecting cracks in the wing attachment ...
Who it affects: All operators of M18 aircraft that have had their M18s inspected using the eddy current procedure QP.00.36 (EC)
Issue owner: Aviation NDT Services Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-06Adequacy of the eddy current inspection procedure
Number: AO-2013-187-SI-06
Description: AO-2013-187-SI-06:The documented procedure for eddy current inspection of M18 wing attachment fittings did not assure repeatable, reliable inspections.
Who it affects: All operators of M18 aircraft that have had their M18s inspected using eddy current procedure QP.00.36 (EC)
Issue owner: Aviation NDT Services Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-187-SI-07Civil Aviation Safety Authority records
Number: AO-2013-187-SI-07
Description: AO-2013-187-SI-07:Important information relating to Civil Aviation Safety Authority (CASA) airworthiness directive AD/PZL/5 was not contained in CASA’s airworthiness directive file, but on other CASA files with no cross-referencing between those files. This impacted CASA’s future ability to reliably discover that information and make appropriately‑informed decisions regarding the airworthiness directive.
Who it affects: All aircraft operators in Australia
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Adequately addressed
Type: Proactive Action
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