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Safety issues and actions
Issue, description, who it affects Date, status, type
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: Safety action pending
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: Safety action pending
Type: 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
Issue, description, who it affects
Issue: AO-2017-005-SI-02Operator’s aircraft loading practices
Number: AO-2017-005-SI-02
Description: AO-2017-005-SI-02:Although the operator’s procedures required that actual weights be used for passengers, baggage and other cargo, this procedure was routinely not followed, and pilots relied on estimated weights when calculating an aircraft’s weight and balance.
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-01Operator’s procedures and practices for airborne inspections of a landing area
Number: AO-2017-005-SI-01
Description: AO-2017-005-SI-01:The operator normally conducted airborne inspections of the Middle Island aeroplane landing area at about 50–100 ft while flying at normal cruise speed towards an area of water, and its procedures did not ensure the effective management of the risk of an engine failure or power loss when at a ...
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-2017-069-SI-04Regulatory differentiation between community service flying and private operations
Number: AO-2017-069-SI-04
Description: AO-2017-069-SI-04:CASA did not have a system to differentiate between community service flights and other private operations, which limited its ability to identify risks. This hindered the Civil Aviation Safety Authority's ability to manage risks associated with community service flights.
Who it affects: All passengers on community service flights conducted by Angel Flight Australia
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 13 Aug 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2017-069-SI-03Availability of safety information to Angel Flight Australia
Number: AO-2017-069-SI-03
Description: AO-2017-069-SI-03:There were limited opportunities for Angel Flight to be made aware of any safety related information involving flights conducted on its behalf.
Who it affects: All pilots conducting community service flights on behalf of Angel Flight Australia
Issue owner: Angel Flight Australia
Operation affected: Aviation: General aviation
Date, status, type
Date: 13 Aug 2019
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2017-069-SI-02Insufficient organisational risk controls implemented by Angel Flight Australia
Number: AO-2017-069-SI-02
Description: AO-2017-069-SI-02:Angel Flight had insufficient controls in place, and provided inadequate guidance to pilots to address the additional operational risks associated with community service flights.
Who it affects: All passengers on community service flights conducted by Angel Flight Australia
Issue owner: Angel Flight Australia
Operation affected: Aviation: General aviation
Date, status, type
Date: 13 Aug 2019
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2017-069-SI-01 Angel Flight Australia consideration of commercial flights
Number: AO-2017-069-SI-01
Description: AO-2017-069-SI-01 :Angel Flight did not consider the safety benefits of commercial passenger flights when suitable flights were available.
Who it affects: All passengers on community service flights conducted by Angel Flight Australia
Issue owner: Angel Flight Australia
Operation affected: Aviation: General aviation
Date, status, type
Date: 13 Aug 2019
Status: Safety action pending
Type: Recommendation
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: Adequately addressed
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: Is incipient spin training permitted in your aircraft?
Description: Operating an aircraft within the stated limitations is essential to the safe conduct of a flight. Training organisations are required to conduct incipient spin recovery training, which includes intentionally inducing a spin and recovering before it fully develops. Some organisations may be conducting this training in aircraft not approved for ...
Who it affects: Flight training organisations
Issue owner:
Operation affected:
Date, status, type
Date: 22 May 2019
Original risk: Significant
Status:
Type: Safety Advisory Notice
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