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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2019-015-SI-01 Aeropower post-training supervision
Number: AO-2019-015-SI-01
Description: AO-2019-015-SI-01 :There were no requirements in Aeropower procedures to provide any post-training supervision for powerline operations. What supervision was provided was ineffective in identifying that a modified stringing method was being used by the pilot.
Issue owner: Aeropower Pty. Ltd.
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Mar 2021
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-025-SI-05Crew risk awareness
Number: AO-2019-025-SI-05
Description: AO-2019-025-SI-05:Although required by the harness instrument commonly issued by the Civil Aviation Safety Authority, the operator did not appraise shooting crews of the risks of using only a harness for restraint during low-level flight.
Issue owner: Jayrow Helicopters
Operation affected: Aviation: General aviation
Date, status, type
Date: 26 Feb 2021
Status: Closed – Adequately addressed
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-025-SI-04Harness instrument clarity
Number: AO-2019-025-SI-04
Description: AO-2019-025-SI-04:A harness instrument, commonly issued by the Civil Aviation Safety Authority (CASA), stated that a harness could be used instead of a seatbelt for take-off and landing. Although not intended by CASA, this instrument was easily able to be misinterpreted as indicating that a seatbelt was not required to be ...
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 26 Feb 2021
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-025-SI-03Aerial platform shooter emergency training
Number: AO-2019-025-SI-03
Description: AO-2019-025-SI-03:Recurrency training and drills in aircraft emergencies were not required for reissue of an aerial platform shooting permission. Some shooters last conducted training about 20 years prior, during initial issue of their permissions.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 26 Feb 2021
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-025-SI-02 The Director of National Parks' risk management
Number: AO-2019-025-SI-02
Description: AO-2019-025-SI-02 :The Director of National Parks did not actively manage the risk of the aerial culling task being conducted in the Kakadu National Park, or effectively supervise the operation. As a result, an increase in the number of crew, a change in helicopter type and change of helicopter operator all progressed ...
Issue owner: Director of National Parks
Operation affected: Aviation: General aviation
Date, status, type
Date: 26 Feb 2021
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: AO-2019-025-SI-01Helmet provision and use
Number: AO-2019-025-SI-01
Description: AO-2019-025-SI-01:Although the Director of National Parks’ safe operating procedures required shooters and spotters to wear helmets during aerial culling tasks, helmets were not provided or used on a routine basis.
Issue owner: Aviation: General aviation
Operation affected: Aviation: General aviation
Date, status, type
Date: 26 Feb 2021
Status: Open – Safety action pending
Type: Proactive action
Issue, description, who it affects
Issue: AO-2017-118-SI-04Fitment of recording devices in light aircraft - International Civil Aviation Organization
Number: AO-2017-118-SI-04
Description: AO-2017-118-SI-04:Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents have been hampered by a lack of recorded data pertaining to the flight. This ...
Issue owner: International Civil Aviation Organization
Operation affected: Aviation: Air transport
Date, status, type
Date: 29 Jan 2021
Status: Open – Safety action pending
Type: Safety recommendation
  Safety advisory notice
  Safety recommendation
Issue, description, who it affects
Issue: AO-2017-118-SI-01No regulatory requirement for carbon monoxide detectors
Number: AO-2017-118-SI-01
Description: AO-2017-118-SI-01:There was no regulatory requirement from the Civil Aviation Safety Authority for piston‑engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 29 Jan 2021
Status: Open – Safety action pending
Type: Proactive action
  Safety recommendation
Issue, description, who it affects
Issue: AO-2017-118-SI-03Fitment of recording devices in light aircraft – Civil Aviation Safety Authority
Number: AO-2017-118-SI-03
Description: AO-2017-118-SI-03:Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non‑identification ...
Issue owner: Civil Aviation Safety Aviation
Operation affected: Aviation: General aviation
Date, status, type
Date: 25 Jan 2021
Status: Open – Safety action pending
Type: Safety recommendation
Issue, description, who it affects
Issue: AO-2017-118-SI-02No monitoring for carbon monoxide detector serviceability
Number: AO-2017-118-SI-02
Description: AO-2017-118-SI-02:Although detectors were not required to be fitted to their aircraft, Sydney Seaplanes had no mechanism for monitoring the serviceability of the carbon monoxide detectors.
Issue owner: Sydney Seaplanes
Operation affected: Aviation: General aviation
Date, status, type
Date: 25 Jan 2021
Status: Closed – Adequately addressed
Type: Proactive action
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
First page Page 1 of 48 Last page Total records: 944