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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2014-053-SI-05 Classification of parachuting operations
Number: AO-2014-053-SI-05
Description: AO-2014-053-SI-05 :Classification of parachuting operations in the private category did not provide comparable risk controls to other similar aviation activities that involve the carriage of the general public for payment.
Who it affects: Australian parachuting industry
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: Safety action pending
Type: Proactive Action
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2014-053-SI-04 Restraint use in parachuting aircraft
Number: AO-2014-053-SI-04
Description: AO-2014-053-SI-04 :It was likely that the parachutists on the accident flight, as well as those that had participated in previous flights, were not secured to the single-point restraints that were fitted to VH-FRT. While research indicates that single-point restraints provide limited protection when compared to dual-point restraints, they do reduce the ...
Who it affects: Australian parachuting industry
Issue owner: Occurrence operator
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: No longer relevant
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2014-053-SI-03Dual-point restraints
Number: AO-2014-053-SI-03
Description: AO-2014-053-SI-03:Research has identified that rear‑facing occupants of parachuting aircraft have a higher chance of survival when secured by dual-point restraints, rather than the standard single-point restraints that were generally fitted to Australian parachuting aircraft.
Who it affects: Australian parachuting industry
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: Safety action pending
Type: Proactive Action
  Recommendation
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2014-053-SI-02Unapproved aircraft flight control modifications
Number: AO-2014-053-SI-02
Description: AO-2014-053-SI-02:Some Cessna 206 parachuting aircraft, including VH-FRT, had their flight control systems modified without an appropriate maintenance procedure or approval. That increased the risk of flight control obstruction.
Who it affects: Parachute jump operators
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-053-SI-01 Secondary seat stop modification not mandatory
Number: AO-2014-053-SI-01
Description: AO-2014-053-SI-01 :Despite being categorised as mandatory for the pilot’s seat by the aircraft manufacturer, a secondary seat stop modification designed to prevent uncommanded rearward pilot seat movement and potential loss of control was not fitted to VH-FRT, nor was it required to be under United States or Australian regulations.
Who it affects: Single engine Cessna aircraft operators
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2016-003-SI-01 Air traffic facilities at Ballina/Byron Gateway Airport
Number: AO-2016-003-SI-01
Description: AO-2016-003-SI-01 :Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence ...
Who it affects: All aircraft operations that utilise Ballina/Byron Gateway Airport
Issue owner: Operator-Ballina/Byron Gateway Airport
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-032-SI-02Consideration of transient elevator deflections from a pitch disconnect
Number: AO-2014-032-SI-02
Description: AO-2014-032-SI-02:The aircraft manufacturer did not account for the transient elevator deflections that occur as a result of the system flexibility and control column input during a pitch disconnect event at all speeds within the flight envelope. As such, there is no assurance that the aircraft has sufficient strength to withstand ...
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 05 May 2017
Status: Safety action pending
Type: Recommendation
  Recommendation
  Recommendation
  Proactive Action
Issue, description, who it affects
Issue: AO-2017-032-SI-01GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Number: AO-2017-032-SI-01
Description: AO-2017-032-SI-01:The ATSB advises that those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3 should note the facts presented in this preliminary report with a view to addressing any risks ...
Who it affects: Those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Issue owner: Operators and maintainers of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Operation affected: Aviation: Air transport
Date, status, type
Date: 13 Apr 2017
Status: Safety action pending
Type: Safety Advisory Notice
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-120-SI-01Emergency oxygen mask and smoke goggles training
Number: AO-2013-120-SI-01
Description: AO-2013-120-SI-01:At the time of the occurrence, the approved QantasLink training did not provide first officers with sufficient familiarity on the use of the oxygen mask and smoke goggles. This likely contributed to the crew's communication difficulties, including with air traffic control.
Who it affects: All QantasLink DHC-8-315 pilots
Issue owner: QantasLink
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Apr 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-005-SI-01Absence of air traffic control procedures and tools for runway changes at Melbourne Airport
Number: AO-2016-005-SI-01
Description: AO-2016-005-SI-01:Airservices Australia did not provide procedures with associated local instructions to Melbourne air traffic controllers regarding how to coordinate runway changes at Melbourne Airport. Furthermore, an absence of system tools increased the risk of the controllers forgetting to coordinate those changes with the Essendon Aerodrome Controller.
Who it affects: Air traffic controllers at Melbourne and Essendon Airports
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 09 Mar 2017
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: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
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: 13 Sep 2016
Status: Adequately addressed
Type: Proactive Action
  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-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-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-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
Issue, description, who it affects
Issue: AO-2013-187-SI-08Assessment of NDT procedures
Number: AO-2013-187-SI-08
Description: AO-2013-187-SI-08:The Civil Aviation Safety Authority did not have a defined process for a robust, systematic approach to the assessment and approval of alternative non-destructive inspection procedures to ensure that the proposed method provided an equivalent, or better, level of safety than the original procedure.
Who it affects: All aircraft operators in Australia
Issue owner: Civil Aviation Safety Authority records
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Feb 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-187-SI-09Australian supplemental type certificate SVA521
Number: AO-2013-187-SI-09
Description: AO-2013-187-SI-09:The engineering justification supporting Australian supplemental type certificate SVA521 did not contain consideration of the effect an increase in the average operating speed could have on the rate of fatigue damage accumulation.
Who it affects: All aircraft operators of the M18 aircraft in Australia operating under STC SVA521
Issue owner: Rebel Ag 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-2014-114-SI-01Flying school spin recovery training
Number: AO-2014-114-SI-01
Description: AO-2014-114-SI-01:The spin recovery methods taught by the flying school were inconsistent across instructors and training material, and were not always appropriate for the Chipmunk aircraft type used by the school.
Who it affects: Instructors and student pilots undertaking aerobatic and spin recovery instruction
Issue owner: Airborne Aviation Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 04 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-226-SI-04Unknown fatigue life of alternative tie rod design
Number: AO-2013-226-SI-04
Description: AO-2013-226-SI-04:When approving the change in material for the manufacture of the replacement tie rods, the design engineer did not identify that the original parts had a life limitation, or that they had shown susceptibility to fatigue cracking. As a result, the engineer did not compare the fatigue performance of the ...
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-226-SI-06Fuselage lateral tie rod Australian Parts Manufacturer Approval
Number: AO-2013-226-SI-06
Description: AO-2013-226-SI-06:It was likely that, because of the Civil Aviation Safety Authority’s policy at the time, their engineering assessment of the tie rod design for inclusion in the manufacturer’s Australian Parts Manufacturer Approval did not consider the service history of the original tie rods or identify that they were subject to ...
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-226-SI-05Australian Parts Manufacturer Approval tie rods not identified by part and serial number
Number: AO-2013-226-SI-05
Description: AO-2013-226-SI-05:The JRA-776-1 fuselage lateral tie rods that were inspected by the ATSB were not appropriately marked with part and serial numbers, affecting the traceability and service history of the parts in a number of aircraft. 
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Issue owner: J & R Aerospace
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-226-SI-02Australian Parts Manufacturer Approval manufacturer’s quality system
Number: AO-2013-226-SI-02
Description: AO-2013-226-SI-02:The manufacturer’s quality system did not prevent non-conforming tie rods from being released for use on aircraft. 
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Issue owner: J & R Aerospace
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2013-226-SI-03Non-standard Joint H fitting upper attachment hardware
Number: AO-2013-226-SI-03
Description: AO-2013-226-SI-03:Together with a number of other Australian Tiger Moths, VH-TSG was fitted with non‑standard Joint H attachment bolts that did not conform to the original design with the result that the integrity of the Joint H could not be assured.
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft
Issue owner: Civil Aviation Safety Authority and de Havilland Support Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-226-SI-07Civil Aviation Safety Authority Australian Parts Manufacturer Approval implementation approvals
Number: AO-2013-226-SI-07
Description: AO-2013-226-SI-07:Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life‑limits, were appropriately considered.
Who it affects: Operators of aircraft fitted with parts manufactured under those Australian Parts Manufacturer Approvals
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Airspace management
Date, status, type
Date: 21 Jan 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2013-226-SI-08Commercial Tiger Moth joy flight operations with high aerobatic utilisation
Number: AO-2013-226-SI-08
Description: AO-2013-226-SI-08:Although a number of aerobatic manoeuvres were permitted in Tiger Moth aircraft, there was no limitation on the amount of aerobatic operations that was considered to be safe. As a result, operators may be unaware that a high aerobatic usage may exceed the original design assumptions for the aircraft. 
Who it affects: Commercial Tiger Moth joy flight operators
Issue owner: de Havilland Support Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2016
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-010-SI-01Unique indications for E Frame on Network control system screens
Number: RO-2015-010-SI-01
Description: RO-2015-010-SI-01:The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 05 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-172-SI-01Uncontained failure of air turbine starter led to loss of engine oil
Number: AO-2013-172-SI-01
Description: AO-2013-172-SI-01:Debris originating from the starter failure was not contained by the starter casing and severed the number one engine B-sump oil scavenge pipe. 
Who it affects: All operators of engines fitted with Honeywell ATS200-61 model starters
Issue owner: Honeywell / General Electric
Operation affected: Aviation: Air transport
Date, status, type
Date: 10 Dec 2015
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2014-162-SI-01Flight crew operating manual procedure for Vref40 check
Number: AO-2014-162-SI-01
Description: AO-2014-162-SI-01:The Flight Crew Operating Manual procedure for crew comparison of the calculated Vref40 speed, while designed to assist in identifying a data entry error, could be misinterpreted, thereby negating the effectiveness of the check.
Who it affects: All Qantas Boeing 737 pilots
Issue owner: Qantas Airways Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Nov 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-160-SI-01Absence of prior planning
Number: AO-2013-160-SI-01
Description: AO-2013-160-SI-01:The applicability of a general requirement to conduct aviation risk assessments for complex, new, unusual or irregular activities was open to interpretation.
Who it affects: Department of Defence air traffic services
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 12 Nov 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-120-SI-01Assigning approaches to foreign operators
Number: AO-2012-120-SI-01
Description: AO-2012-120-SI-01:Unlike other Australian standard arrival routes that included a visual segment, the visual approach to runway 34 at Melbourne via the SHEED waypoint could be issued to super or heavy jet aircraft operated by foreign operators, despite there being more occurrences involving the SHEED waypoint than other comparable approaches.
Who it affects: All foreign operators of super or heavy jet aircraft conducting a visual approach to runway 34 at Melbourne via the SHEED waypoint
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 01 Sep 2015
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2012-120-SI-02Design of the LIZZI FIVE RWY 34 VICTOR ARRIVAL at Melbourne Airport
Number: AO-2012-120-SI-02
Description: AO-2012-120-SI-02:The LIZZI FIVE RWY 34 VICTOR ARRIVAL required a 3.5° descent profile after passing the SHEED waypoint for visual approach to runway 34 at Melbourne, increasing the risk of an unstable approach.
Who it affects: All flight crew of large jet aircraft conducting the visual approach via SHEED waypoint to runway 34 at Melbourne.
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Airspace management
Date, status, type
Date: 01 Sep 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-095-SI-01Annunciation of mode changes
Number: AO-2013-095-SI-01
Description: AO-2013-095-SI-01:The Virgin Australia procedures did not require its flight crews to, whenever practicable, announce flight mode changes.
Who it affects: Virgin Australia flight crews
Issue owner: Virgin Australia
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Aug 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-095-SI-02 Provision of traffic information
Number: AO-2013-095-SI-02
Description: AO-2013-095-SI-02 :Air traffic control did not, and was not required to provide traffic information to aircraft using adjacent runways and abeam each other during independent visual approach procedures at Sydney.
Who it affects: All Sydney Terminal Control Unit Director controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 07 Aug 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-130-SI-01Guidance material
Number: AO-2013-130-SI-01
Description: AO-2013-130-SI-01:The presentation of the runway 34 visual approach in the operator's Route and Airport Information Manual increased the risk of the runway threshold crossing altitude being entered into the runway extension waypoint.
Who it affects: Virgin Australia International Airlines B777 pilots
Issue owner: Virgin Australia International Airlines
Operation affected: Aviation: Air transport
Date, status, type
Date: 15 Jul 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-047-SI-01Visual approach guidance
Number: AO-2013-047-SI-01
Description: AO-2013-047-SI-01:Qantas provided limited guidance on the conduct of a visual approach and the associated briefing required to enable the flight crew to have a shared understanding of the intended approach.
Who it affects: Flight crew
Issue owner: Qantas
Operation affected: Aviation: Air transport
Date, status, type
Date: 09 Jul 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-055-SI-02Fitment of bladder-type fuel tanks to R44 helicopters (US)
Number: AO-2013-055-SI-02
Description: AO-2013-055-SI-02:Accidents involving Robinson R44 helicopters without bladder-type tanks fitted result in a significantly higher proportion of post-impact fires than for other similar helicopter types. In addition, the existing United States regulatory arrangements are not sufficient to ensure all R44 operators and owners comply with the manufacturer's Service Bulletin SB-78B and ...
Who it affects: All owners and operators of R44 helicopters
Issue owner: United States Federal Aviation Administration
Operation affected: Aviation: General aviation
Date, status, type
Date: 04 Jun 2015
Status: Safety action pending
Type: Recommendation
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-055-SI-03Helicopters not manufactured with a crash-resistant fuel system
Number: AO-2013-055-SI-03
Description: AO-2013-055-SI-03:Although certification requirements for helicopters to include a crash-resistant fuel system (CRFS) were introduced in 1994, several helicopter types certified before these requirements became applicable are still being manufactured without a CRFS.
Who it affects: All owners and operators of helicopters not fitted with crash-resistant fuel systems
Issue owner: United States Federal Aviation Administration
Operation affected: Aviation: General aviation
Date, status, type
Date: 04 Jun 2015
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2013-055-SI-04 Existing helicopters not fitted with a crash-resistant fuel system
Number: AO-2013-055-SI-04
Description: AO-2013-055-SI-04 :Many of the existing civil helicopter fleet are not fitted with a crash-resistant fuel system, or do not have an equivalent level of safety associated with post-impact fire prevention.
Who it affects: All owners and operators of aircraft not fitted with crash-resistant fuel systems
Issue owner: United States Federal Aviation Administration
Operation affected: Aviation: General aviation
Date, status, type
Date: 04 Jun 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
  Recommendation
Issue, description, who it affects
Issue: AO-2012-132-SI-01Controller training for black ‘not concerned’ track awareness
Number: AO-2012-132-SI-01
Description: AO-2012-132-SI-01:Controllers were routinely exposed to ‘not concerned’ radar tracks that were generally inconsequential in the en route environment, leading to a high level of expectancy that such tracks were not relevant for aircraft separation purposes. Training did not emphasise the importance of scanning ‘not concerned’ radar tracks in jurisdiction airspace.
Who it affects: All Airservices Australia en route air traffic controllers providing surveillance services
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 20 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-132-SI-02Limited system features for protection against inhibited tracks
Number: AO-2012-132-SI-02
Description: AO-2012-132-SI-02:The limited interoperability between The Australian Advanced Air Traffic System and Australian Defence Air Traffic System increased the risk of error due to the need for a number of manual interventions or processes to facilitate the coordination and processing of traffic.
Who it affects: All Airservices Australia en route air traffic controllers providing surveillance services
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 20 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-085-SI-03Virgin Australia Regional Airlines Pty Ltd TAWS under reporting
Number: AO-2013-085-SI-03
Description: AO-2013-085-SI-03:There was a significant underreporting by Virgin Australia Regional Airlines Pty Ltd ATR72 terrain awareness warning system-related occurrences.
Who it affects: Virgin Australia Regional Airlines flight crew
Issue owner: Virgin Australia Regional Airlines Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 12 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-161-SI-01Convergent air routes and airspace sectorisation
Number: AO-2013-161-SI-01
Description: AO-2013-161-SI-01:The convergence of many published air routes overhead Adelaide, combined with the convergence point being positioned on the sector boundary of the Augusta and Tailem Bend sectors, reduced the separation assurance provided by strategically separated one-way air routes and increased the potential requirement for controller intervention to assure separation.
Who it affects: All Augusta and Tailem Bend en route controllers, and associated airspace users
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 05 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-116-SI-01Go-around preparedness
Number: AO-2012-116-SI-01
Description: AO-2012-116-SI-01:All-engine go-arounds in modern air transport aircraft are often a challenging task when there is a requirement to level-off at a low altitude, and many pilots have had limited preparation for this task.
Who it affects: All operators and flight crew of modern air transport aircraft
Issue owner: Jetstar Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 03 Nov 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2012-138-SI-01Required navigation performance approach procedure
Number: AO-2012-138-SI-01
Description: AO-2012-138-SI-01:The company’s Required Navigation Performance approach procedure allowed the flight crew to set the approach minimum altitude in the auto-flight system prior to commencing the approach. This did not ensure the altitude alerting system reflected the assigned altitude limit of 7,000 ft and removed the defence of that alert when ...
Who it affects: Flight crew conducting RNP-AR operations
Issue owner: Qantas Airways Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 29 Oct 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-131-SI-03CADAS risk assessment and review process
Number: AO-2012-131-SI-03
Description: AO-2012-131-SI-03:The Department of Defence’s risk assessment and review processes for the implementation of the Comsoft Aeronautical Data Access System and removal of the flight data position did not effectively identify or manage the risks associated with the resulting increased workload in the Darwin Approach environment, in particular with regard to ...
Who it affects: All Darwin Approach Supervisor, Approach and Planner rated Joint Battlefield Airspace Controllers
Issue owner: Department of Defence
Operation affected: Aviation: Other
Date, status, type
Date: 02 Oct 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-131-SI-04Long-range display effectiveness
Number: AO-2012-131-SI-04
Description: AO-2012-131-SI-04:The Darwin Approach long-range display was a low resolution screen that presented air traffic control system information with reduced clarity and resulted in it having diminished effectiveness as a situation awareness tool.
Who it affects: All Darwin Approach rated Joint Battlefield Airspace Controllers
Issue owner: Department of Defence
Operation affected: Aviation: Other
Date, status, type
Date: 02 Oct 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-131-SI-05Compromised separation recovery refresher training
Number: AO-2012-131-SI-05
Description: AO-2012-131-SI-05:The Department of Defence had not provided Darwin-based controllers with regular practical refresher training in identifying and responding to compromised separation scenarios.
Who it affects: All Darwin-based Joint Battlefield Airspace Controllers
Issue owner: Department of Defence
Operation affected: Aviation: Other
Date, status, type
Date: 02 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: AO-2012-131-SI-01Risk controls for manual processing of transponder code changes
Number: AO-2012-131-SI-01
Description: AO-2012-131-SI-01:The Australian Defence Air Traffic System (ADATS) did not automatically process all system messages generated by The Australian Advanced Air Traffic System. In cases where transponder code changes were not automatically processed, the risk controls in place were not able to effectively ensure that the changes were identified and manually ...
Who it affects: All Darwin Approach Supervisor, Approach and Planner rated Joint Battlefield Airspace Controllers
Issue owner: Department of Defence
Operation affected: Aviation: Other
Date, status, type
Date: 02 Oct 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-131-SI-02Controller scan of green radar returns
Number: AO-2012-131-SI-02
Description: AO-2012-131-SI-02:Darwin Approach controllers were routinely exposed to green (limited data block) radar returns that were generally inconsequential in that Approach control environment, leading to a high level of expectancy that such tracks were not relevant for aircraft separation purposes. Refresher training did not emphasise the importance of scanning the green ...
Who it affects: All Darwin Approach Supervisor, Approach and Planner rated Joint Battlefield Airspace Controllers
Issue owner: Department of Defence
Operation affected: Aviation: Other
Date, status, type
Date: 02 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: AO-2012-024-SI-01Routing of landing gear selector valve electrical harness
Number: AO-2012-024-SI-01
Description: AO-2012-024-SI-01:The proximity of the landing gear selector valve electrical wiring loom to the external hydraulic power connectors within the left engine nacelle on Fairchild SA227-AT Metro aircraft resulted in the ‘down selection’ wire being damaged during routine maintenance activities.
Who it affects: All owners and operators of SA227 aircraft
Issue owner: Elbit Systems of America
Operation affected: Aviation: Other
Date, status, type
Date: 29 Sep 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-010-SI-01Fatigue management
Number: AO-2013-010-SI-01
Description: AO-2013-010-SI-01:Although the operator’s rostering practices were consistent with the existing regulatory requirements, it had limited processes in place to proactively manage its flight crew rosters and ensure that fatigue risk due to restricted sleep was effectively minimised.
Who it affects: The operator’s flight crews
Issue owner: Airnorth
Operation affected: Aviation: Air transport
Date, status, type
Date: 22 Aug 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-046-SI-01Engines with un-doweled crankshaft–propeller flange joints
Number: AO-2013-046-SI-01
Description: AO-2013-046-SI-01:Jabiru engines manufactured before July 2011 have reduced strength and reliability of the crankshaft/propeller flange joint, compared with the later design that incorporated positive location dowel pins.
Who it affects: All owners and operators of Jabiru J230 & J430 aircraft with an engine number before 33A2446 i.e. 2,445 pre-July 2011 engines.
Issue owner: Jabiru Aircraft Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 19 Aug 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-046-SI-02Insufficient joint clamping
Number: AO-2013-046-SI-02
Description: AO-2013-046-SI-02:The manufacturer’s specified procedure for assembling and torqueing of the crankshaft/propeller flange fasteners was ineffective in ensuring resistance against subsequent joint movement in service.
Who it affects: All owners and operators of Jabiru J230 & J430 aircraft
Issue owner: Jabiru Aircraft Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 19 Aug 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-046-SI-03Documentation anomalies
Number: AO-2013-046-SI-03
Description: AO-2013-046-SI-03:The engine manufacturer’s documents with respect to the propeller mounting flange were technically inconsistent with regard to painting and torqueing procedures.
Who it affects: All owners and operators of Jabiru J230 & J430 aircraft
Issue owner: Jabiru Aircraft Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 19 Aug 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-021-SI-02 Track inspections frequency
Number: RO-2013-021-SI-02
Description: RO-2013-021-SI-02 :Track walking inspections were not conducted at intervals specified by V/Line’s maintenance program
Who it affects: All operators of freight trains and infrastructure managers.
Issue owner: V/Line Regional Network and Access
Operation affected: Rail: Operations control
Date, status, type
Date: 01 Aug 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-126-SI-01Pilot training
Number: AO-2011-126-SI-01
Description: AO-2011-126-SI-01:The training provided to the pilot did not afford him the opportunity to develop the competencies required to exercise the privileges of the Recreational Aviation Australia Incorporated private pilot certificate.
Who it affects: Operator of the Taree flight training facility
Issue owner: Recreational Aviation Australia Incorporated
Operation affected: Aviation: General aviation
Date, status, type
Date: 17 Apr 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-126-SI-02Risk management of aviation activities
Number: AO-2011-126-SI-02
Description: AO-2011-126-SI-02:The approach to the management of risk at the Old Bar Beach Festival, particularly specifically in relation to aviation activities, was ineffective and resulted in a high level of unmanaged risk that had the potential to impact on the objectives of the festival.
Who it affects: All organisers of events for the general public that include aviation related activities, including festivals, fairs, exhibitions and air shows
Issue owner: Old Bar Beach Festival Committee, Old Bar Airstrip Committee, Greater Taree City Council
Operation affected: Aviation: Other
Date, status, type
Date: 17 Apr 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2011-126-SI-03Aircraft construction and certification
Number: AO-2011-126-SI-03
Description: AO-2011-126-SI-03:The manufacture of, and the processes used to certify and register the Morgan Aero Works Cheetah Sierra 200 aircraft, resulted in an increased risk to persons entering the recreational aviation community and using the aircraft for flight training, and also to the general public.
Who it affects: All manufacturers of light sport aircraft
Issue owner: Recreational Aviation Australia Incorporated
Operation affected: Aviation: Other
Date, status, type
Date: 17 Apr 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-103-SI-01Descent mode management and Flight Control Unit altitude selection
Number: AO-2012-103-SI-01
Description: AO-2012-103-SI-01:The operator’s procedures did not require the flight crew to specifically check the active auto-flight mode during descent, and allowed the crew to select the Vertical Intercept Point altitude when cleared for the approach by air traffic control. This combination of procedures provided limited protection against descent through an instrument ...
Who it affects: All operators of highly-automated aircraft
Issue owner: Jetstar Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 13 Mar 2014
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-047-SI-01Temporary Restricted Area management processes
Number: AO-2012-047-SI-01
Description: AO-2012-047-SI-01:Airservices Australia’s processes for managing a Temporary Restricted Area did not effectively ensure that all aircraft operating in the Temporary Restricted Area were known to air traffic services.
Who it affects: All aircraft operators
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 28 Feb 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: AO-2012-047-SI-02Contingency Response Manager selection and preparation processes
Number: AO-2012-047-SI-02
Description: AO-2012-047-SI-02:Airservices Australia’s processes for selecting and preparing personnel for the Contingency Response Manager role did not ensure they could effectively perform that role.
Who it affects: All Airservices Australia’s Contingency Response Managers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 28 Feb 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-047-SI-03Contingency plan testing and review effectiveness
Number: AO-2012-047-SI-03
Description: AO-2012-047-SI-03:Airservices Australia’s processes for reviewing and testing contingency plans did not effectively ensure that all documented contingency plan details were current and that its contingency plans could be successfully implemented at short notice.
Who it affects: All Airservices Australia air traffic controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 28 Feb 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: AO-2012-047-SI-04Fatigue monitoring of Air Traffic Control Line Managers
Number: AO-2012-047-SI-04
Description: AO-2012-047-SI-04:Airservices Australia did not have a defined process for recording the actual hours worked by its Air Traffic Control Line Managers and therefore could not accurately monitor the potential fatigue of those personnel when they were performing operational roles such as a Shift Manager or Contingency Response Manager.
Who it affects: All Airservices Australia’s Air Traffic Control Line Managers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 28 Feb 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-226-SI-01Fuselage lateral tie rod fatigue cracks
Number: AO-2013-226-SI-01
Description: AO-2013-226-SI-01:The two JRA-776-1 fuselage lateral tie rods fitted to de Havilland DH82A Tiger Moth, registered VH-TSG, had significant, pre-existing fatigue cracks in the threaded sections. The parts’ service life was significantly less than the published retirement life for DH82A tie rods of 2,000 flight hours or 18 years).
Who it affects: Owners and operators of DH82 and DH82A Tiger Moth aircraft fitted with JRA 776 1 fuselage lateral tie rods
Issue owner: United Kingdom Civil Aviation Authority and the Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 24 Feb 2014
Status: Adequately addressed
Type: Safety Advisory Notice
  Proactive Action
Issue, description, who it affects
Issue: AO-2011-110-SI-01Inexperienced pilot tasked for flight
Number: AO-2011-110-SI-01
Description: AO-2011-110-SI-01:The pilot was assigned to a task for which he most likely lacked experience on both the helicopter type and the nature of the flying.
Who it affects: Heli Charters Australia Pty Ltd
Issue owner: Heli Charters Pty Ltd
Operation affected: Aviation: Other
Date, status, type
Date: 18 Feb 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-110-SI-02Hazardous helicopter landing site
Number: AO-2011-110-SI-02
Description: AO-2011-110-SI-02:The minimal clearance from obstructions, unfavourable surface conditions and a lack of appropriate wind indication at the helicopter landing site (HLS) increased the risk associated with operations to the HLS, particularly for a pilot unfamiliar with the site. 
Who it affects: All helicopter landing site owners
Issue owner: Helicopter landing site owners
Operation affected: Aviation: Other
Date, status, type
Date: 18 Feb 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-135-SI-01Production release of partially-embrittled MS21042L-4 nuts
Number: AO-2011-135-SI-01
Description: AO-2011-135-SI-01:The nut manufacturer’s production control and quality control processes failed to prevent the release of one or more lots of MS21042L-4 nuts that remained in a partially-embrittled state after cadmium electroplating.
Who it affects: All owners and operators of aircraft using MS21042 and related nuts
Issue owner: Airfasco Industries Fastener Group
Operation affected: Aviation: Air transport
Date, status, type
Date: 22 Jan 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-135-SI-02Awareness of the potential for nut failure
Number: AO-2011-135-SI-02
Description: AO-2011-135-SI-02:At the time of the occurrence there was limited advisory material available to owners, operators and maintenance personnel to alert them to the possibility of MS21042 nut failure and to assist with appropriately detailed inspections aimed at identifying affected items.
Who it affects: All owners and operators of aircraft using MS21042 and related nuts
Issue owner: Manufacturers of aircraft using MS21042 and related nuts, and relevant regulatory agencies
Operation affected: Aviation: Air transport
Date, status, type
Date: 22 Jan 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2012-130-SI-01Provision of assistance to aircraft in distress
Number: AO-2012-130-SI-01
Description: AO-2012-130-SI-01:Though airborne search and rescue service providers were regularly tasked to provide assistance to pilots in distress, there was limited specific guidance on the conduct of such assistance.
Who it affects: Aeroplane and helicopter search and rescue (SAR) service providers
Issue owner: Airservices Australia, Australian Maritime Safety Authority
Operation affected: Aviation: Other
Date, status, type
Date: 19 Dec 2013
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2011-076-SI-01Tiger Airways Australia Pty Ltd documentation discrepancies
Number: AO-2011-076-SI-01
Description: AO-2011-076-SI-01:The Tiger Airways Australia Pty Ltd documentation and training package relating to the Avalon airspace structure and night visual approach guidance contained incorrect material and omissions that increased the risk of confusion and misunderstanding by flight crews.
Who it affects: Tiger Airways Australia flight crews
Issue owner: Tiger Airways Australia Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-076-SI-02Air traffic services procedures
Number: AO-2011-076-SI-02
Description: AO-2011-076-SI-02:The Manual of Air Traffic Services differed from the Civil Aviation Safety Regulation Part 172 Manual of Standards concerning the requirements for issuing a night visual approach to an instrument flight rules aircraft, increasing the risk of ambiguity in the application of these requirements by controllers.
Who it affects: Air traffic controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-142-SI-01Procedures to establish separation assurance
Number: AO-2011-142-SI-01
Description: AO-2011-142-SI-01:There was no documented procedure for assuring the separation of aircraft departing from Sydney with parachute operations at Richmond, increasing the likelihood that Sydney Terminal Control Unit controllers would have differing expectations as to their control and coordination requirements in respect of these operations.
Who it affects: All Sydney Terminal Control Unit Sydney Approach West and Sydney Departures South controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 16 Dec 2013
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-142-SI-02Drop clearance indication procedures
Number: AO-2011-142-SI-02
Description: AO-2011-142-SI-02:Local and national air traffic control procedures did not prescribe the means for controllers to indicate in the air traffic control system that a parachute drop clearance had been issued.
Who it affects: All controllers using The Australian Advanced Air Traffic System
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 16 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-100-SI-01Requirements for visual flight rules flights in dark night conditions
Number: AO-2011-100-SI-01
Description: AO-2011-100-SI-01:Aerial work and private flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.
Who it affects: All aircraft operating under the night visual flight rules
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 03 Dec 2013
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2011-102-SI-02Requirements for visual flight rule flights in dark night conditions
Number: AO-2011-102-SI-02
Description: AO-2011-102-SI-02:Aerial work and private flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.
Who it affects: All aircraft operating under the night visual flight rules (VFR)
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 08 Nov 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2011-102-SI-03Requirements for autopilots in dark night conditions
Number: AO-2011-102-SI-03
Description: AO-2011-102-SI-03:Helicopter flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without the same requirements for autopilots and similar systems that are in place for conducting flights under the instrument flight rules.
Who it affects: All helicopters operating under the night VFR
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 08 Nov 2013
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2011-102-SI-01Operator’s processes for managing operations
Number: AO-2011-102-SI-01
Description: AO-2011-102-SI-01:Although some of the operator’s risk controls for the conduct of night visual flight rules flights were in excess of the regulatory requirements, the operator did not effectively manage the risk associated with operations in dark night conditions.
Who it affects: The operator’s flight crew
Issue owner: The operator of the helicopter
Operation affected: Aviation: General aviation
Date, status, type
Date: 08 Nov 2013
Status: No longer relevant
Issue, description, who it affects
Issue: AO-2012-142-SI-01Airfield marking
Number: AO-2012-142-SI-01
Description: AO-2012-142-SI-01:The aircraft landing area did not have clearly defined threshold markings making the mown undershoot area difficult to distinguish from the airstrip.
Who it affects: ALA owners
Issue owner: Owner of the aircraft landing area (ALA)
Operation affected: Aviation: Maintenance
Date, status, type
Date: 07 Nov 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-142-SI-02Powerline marking
Number: AO-2012-142-SI-02
Description: AO-2012-142-SI-02:The powerlines were not marked with high visibility devices, nor were they required to be so marked by the relevant Australian Standard. This reduced the likelihood of a pilot detecting the position of the wires.
Who it affects: ALA owners
Issue owner: Owner of the ALA
Operation affected: Aviation: General aviation
Date, status, type
Date: 07 Nov 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-049-SI-01Ayers Corporation S2R-G10 Thrush operating weight
Number: AO-2012-049-SI-01
Description: AO-2012-049-SI-01:The Ayers Corporation S2R-G10 Thrush aircraft type had a published maximum take-off weight that was not practical for agricultural use, increasing the risk that pilots would operate the aircraft above the published maximum weight and potentially at unsafe weights.
Who it affects: Pilots who operate Thrush aircraft
Issue owner: Statewide Aviation
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AR-2012-034-SI-01Military ATS risk
Number: AR-2012-034-SI-01
Description: AR-2012-034-SI-01:There was a disproportionate rate of loss of separation incidents which leads to a higher risk of collision in military terminal area airspace in general and all airspace around Darwin and Williamtown in particular. Furthermore, loss of separation incidents in military airspace more commonly involved contributing air traffic controller actions ...
Who it affects: All civilian aircraft operations into military controlled airspace
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AR-2012-034-SI-02Regulatory oversight of military air traffic services
Number: AR-2012-034-SI-02
Description: AR-2012-034-SI-02:Regulatory oversight processes for military air traffic services do not provide independent assessment and assurance as to the safety of civilian aircraft operations.
Who it affects: All civilian aircraft operations into military controlled airspace
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: AR-2012-034-SI-03Using all information to monitor separation risk
Number: AR-2012-034-SI-03
Description: AR-2012-034-SI-03:Loss of separation (LOS) incidents attributable to pilot actions in civil airspace are not monitored as a measure of airspace safety nor actively investigated for insight into possible improvements to air traffic service provision. As about half of all LOS incidents are from pilot actions, not all available information is ...
Who it affects: All civilian aircraft operations into military controlled airspace
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: AO-2011-144-SI-01Controller workload monitoring and management
Number: AO-2011-144-SI-01
Description: AO-2011-144-SI-01:The air traffic controller provider’s processes for monitoring and managing controller workloads did not ensure that newly-endorsed controllers had sufficient skills and techniques to manage the high workload situations to which they were exposed.
Who it affects: All relatively inexperienced controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-144-SI-02Allocation of additional duty periods
Number: AO-2011-144-SI-02
Description: AO-2011-144-SI-02:The air traffic services provider’s fatigue risk management system (FRMS) did not effectively manage the fatigue risk associated with allocating additional duty periods.
Who it affects: All controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-144-SI-03Procedural air traffic control conflict detection system
Number: AO-2011-144-SI-03
Description: AO-2011-144-SI-03:Although the air traffic services provider has been working on the issue for several years, there was still no automated air traffic conflict detection system available for conflictions involving aircraft that were not subject to radar or ADS-B surveillance services.
Who it affects: All en route flights under procedural control
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-012-SI-03Limited guidance for block level clearances
Number: AO-2012-012-SI-03
Description: AO-2012-012-SI-03:The air traffic services provider had limited formal guidance to controllers and pilots regarding the conditions in which it was safe and appropriate to use block levels.
Who it affects: Air traffic control – all operation types
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: AO-2012-012-SI-04No conflcition detection system for procedural ATC
Number: AO-2012-012-SI-04
Description: AO-2012-012-SI-04:Although the air traffic services provider has been working on the issue for several years, there was still no automated air traffic conflict detection system available for conflictions involving aircraft that were not subject to radar or ADS-B surveillance services.
Who it affects: Air traffic control – all operation types
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-012-SI-02Limited formal guidance for consolidation periods
Number: AO-2012-012-SI-02
Description: AO-2012-012-SI-02:The air traffic services provider had limited formal guidance regarding how to determine appropriate consolidation periods for en route controllers on one sector before they were transitioned to commence training on another sector.
Who it affects: Air traffic control – all operation types
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: AO-2012-012-SI-01Processes for monitoring controller workloads
Number: AO-2012-012-SI-01
Description: AO-2012-012-SI-01:The air traffic services provider’s processes for monitoring and managing controller workloads did not ensure that newly-endorsed controllers had sufficient skills and techniques to manage the high workload situations to which they were exposed.
Who it affects: Air traffic control - all operation types
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 18 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-136-SI-01Limited documented guidance for rescue equipment selection
Number: AO-2013-136-SI-01
Description: AO-2013-136-SI-01:Limited guidance was provided by the operator and Air Ambulance Victoria for to crews on the selection of the most appropriate winch rescue equipment given operational and medical considerations, and the conditions when various types of equipment should be considered.
Who it affects: Operators carrying out winching operations
Issue owner: Australian Helicopters
Operation affected: Aviation: General aviation
Date, status, type
Date: 10 Oct 2013
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2012-150-SI-01High pressure turbine stage-2 nozzle distress
Number: AO-2012-150-SI-01
Description: AO-2012-150-SI-01:The design cooling characteristics of the Engine Alliance GP7200 high pressure turbine (HPT) stage-2 nozzle components led to higher than expected metal surface temperatures during operation, rendering the nozzles susceptible to distress, premature degradation and failure.
Who it affects: All operators of A380 aircraft with Engine Alliance GP7200 engines fitted
Issue owner: Engine Alliance
Operation affected: Aviation: Air transport
Date, status, type
Date: 09 Sep 2013
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2012-150-SI-02Engine trend monitoring limits
Number: AO-2012-150-SI-02
Description: AO-2012-150-SI-02:The threshold limits for the engine trend monitoring program were not set at a level that provided sufficient opportunity for inspection of the engine before failure could occur from the effects of HPT stage-2 nozzle degradation.
Who it affects: All operators of A380 aircraft with Engine Alliance GP7200 engines fitted
Issue owner: Engine Alliance
Operation affected: Aviation: Air transport
Date, status, type
Date: 09 Sep 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-115-SI-01Regulatory requirements for class B aircraft maintenance
Number: AO-2011-115-SI-01
Description: AO-2011-115-SI-01:The Civil Aviation Regulations 1988 allow class B aircraft registration holders to maintain their aircraft using the CASA maintenance schedule in situations where a more appropriate manufacturer’s maintenance schedule exists.
Who it affects: All registration holders of class B aircraft
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 16 Aug 2013
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2011-115-SI-02Regulatory requirements for manufacturers’ supplemental inspections
Number: AO-2011-115-SI-02
Description: AO-2011-115-SI-02:The Civil Aviation Regulations 1988 lack clarity regarding the requirement for aircraft manufacturers’ supplemental inspections, where available, to be carried out when an aircraft is being maintained in accordance with the CASA maintenance schedule.
Who it affects: All registration holders of class B aircraft
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 16 Aug 2013
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2013-116-SI-01Safety Advisory Notice
Number: AO-2013-116-SI-01
Description: AO-2013-116-SI-01:The Australian Transport Safety Bureau advises balloon operators to review their risk controls in relation to the safety of cold-air inflation fans, especially in relation to passenger proximity to operating fans, and the security of loose items, such as passenger clothing. 
Who it affects: Balloon operators
Issue owner: Kavanagh Balloons
Operation affected: Aviation: General aviation
Date, status, type
Date: 26 Jul 2013
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2010-089-SI-03Release of non-conforming oil feed stub pipes into service
Number: AO-2010-089-SI-03
Description: AO-2010-089-SI-03:Numerous other engines within the Trent 900 fleet were also found to contain a critical reduction in the oil feed stub pipe wall thickness.
Who it affects: Rolls-Royce plc, owners and operators of Trent 900 engines
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-04Consultation between manufacturing engineers and design engineers to ensure maintenance of design intent
Number: AO-2010-089-SI-04
Description: AO-2010-089-SI-04:The engine manufacturer did not require its manufacturing engineers to consult with the design engineers to ensure that design intent would be maintained when introducing manufacturing datums.
Who it affects: Engine manufacturer Rolls-Royce plc
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-05Use of manufacturing stage drawings for the first article inspection
Number: AO-2010-089-SI-05
Description: AO-2010-089-SI-05:The procedure for the first article inspection process contained ambiguities that resulted in an interpretation whereby the use of the manufacturing stage drawings was deemed to be acceptable.
Who it affects: Engine manufacturer Rolls-Royce plc
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-06Culture of acceptance of ‘minor’ non-conforming components during manufacture at the Rolls-Royce Hucknall facility
Number: AO-2010-089-SI-06
Description: AO-2010-089-SI-06:A culture existed within the engine manufacturer's Hucknall facility where it was considered acceptable to not declare what manufacturing personnel determined to be minor non-conformances in manufactured components.
Who it affects: Engine manufacturer Rolls-Royce plc
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-07Difference between drawing datum and coordinate measuring machine datum
Number: AO-2010-089-SI-07
Description: AO-2010-089-SI-07:The coordinate measuring machine was programmed to measure the location of the oil feed stub pipe interference bore with respect to the manufacturing datum, instead of the design definition datum as specified on both the design and manufacturing stage drawings.
Who it affects: Engine manufacturer Rolls-Royce plc
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-08Expert review of statistical analysis in support of retrospective concessions
Number: AO-2010-089-SI-08
Description: AO-2010-089-SI-08:The engine manufacturer did not have a requirement for an expert review of statistical analyses used in retrospective concession applications.
Who it affects: Engine manufacturer Rolls-Royce plc
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-09Chief Engineer and Business Quality Director review of retrospective concessions
Number: AO-2010-089-SI-09
Description: AO-2010-089-SI-09:The engine manufacturer's process for retrospective concessions did not specify when in the process the Chief Engineer and Business Quality Director approvals were to be obtained. Having them as the final approval in the process resulted in an increased probability that the fleet-wide risk assessment would not occur.
Who it affects: Rolls-Royce plc
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-11Classification of the HP/IP bearing support assembly
Number: AO-2010-089-SI-11
Description: AO-2010-089-SI-11:The manufacturer’s classification, relating to the criticality of failure, of the HP/IP bearing support assembly was inappropriate for the effects of a fire within the buffer space and hence, the requirement for an appropriate level of process control was not communicated to the manufacturing staff.
Who it affects: Engine manufacturer Rolls-Royce plc
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-12Landing distance calculation at aircraft weights below the A380 maximum landing weight
Number: AO-2010-089-SI-12
Description: AO-2010-089-SI-12:The calculation method in the aircraft manufacturer’s landing distance performance application was overly conservative and this could prevent the calculation of a valid landing distance at weights below the maximum landing weight with multiple system failures.
Who it affects: Airbus SAS and operators of A380 aircraft
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-13Airframe certification standards in the case of an uncontained engine rotor failure - EASA and FAA
Number: AO-2010-089-SI-13
Description: AO-2010-089-SI-13:The evolution of the current advisory material relating to the minimisation of hazards resulting from uncontained engine rotor failures was based on service experience, including accident investigation findings. The damage to Airbus A380-842 VH-OQA exceeded the modelling used in the UERF safety analysis and, therefore, represents an opportunity to incorporate ...
Who it affects: Airframe certification authorities
Issue owner: European Aviation Safety Agency and the US Federal Aviation Administration
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jun 2013
Status: Partially addressed
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: AO-2010-089-SI-10Reporting of significant non-conformances to the quality review board
Number: AO-2010-089-SI-10
Description: AO-2010-089-SI-10:The engine manufacturer’s group quality procedures did not provide any guidance on how manufacturing personnel were to determine the significance of a non-conformance, from a quality assurance perspective.
Who it affects: Engine manufacturer Rolls-Royce plc
Issue owner: Rolls-Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 26 Jun 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-166-04External lighting in the operator’s AW139 helicopters
Number: AO-2011-166-04
Description: AO-2011-166-04:The helicopter’s lighting set-up did not allow independent control of the searchlights by the pilot using the switches on the flight controls, as required by the operations manual and Civil Aviation Order 29.11, and increased the risk of loss of hover reference and distraction in the case of a single ...
Who it affects: The helicopter operator
Issue owner: The helicopter operator
Operation affected: Aviation: General aviation
Date, status, type
Date: 16 May 2013
Status:
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-166-02Role of the Ambulance Service of NSW specialty casualty access team
Number: AO-2011-166-02
Description: AO-2011-166-02:The increased capability of helicopters and rescue winches enabled the conduct of complex winch rescues beyond the current level of winch training and procedural support associated with the traditional special casualty access team clinical access role, leading to an increased risk that hazards associated with complex rescues were not identified.
Who it affects: Ambulance Service of NSW specialty casualty access team
Issue owner: Ambulance Service of NSW
Operation affected: Aviation: Other
Date, status, type
Date: 16 May 2013
Status:
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-166-03Night winching recency training
Number: AO-2011-166-03
Description: AO-2011-166-03:Ambulance rescue crewmen did not conduct any night winching recency training, resulting in an increased risk of unfamiliarity with night winching procedures and their associated hazards.
Who it affects: Special casualty access training
Issue owner: Ambulance Service of NSW
Operation affected: Aviation: Other
Date, status, type
Date: 16 May 2013
Status:
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-166-01Ambulance Service of NSW specialty casualty access team operating procedures
Number: AO-2011-166-01
Description: AO-2011-166-01:The accepted use of procedural adaptation by special casualty access team paramedics, and the past success of rescues that involved adapted techniques, probably led to the retrieval procedure that was used on the night.
Who it affects: Ambulance Service of NSW specialty casualty access teams
Issue owner: Ambulance Service of NSW
Operation affected: Aviation: Other
Date, status, type
Date: 16 May 2013
Status:
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-021-SI-01Fitment of rubber, bladder-type fuel tanks to R44 helicopters
Number: AO-2012-021-SI-01
Description: AO-2012-021-SI-01:A significant number of R44 helicopters, including VH-COK, were not fitted with bladder-type fuel tanks and the other modifications detailed in the manufacturer's Service Bulletin, SB-78 to improve resistance to post?impact fuel leaks and fire.
Who it affects: All owners and operators of R44 helicopters
Issue owner: Robinson Helicopter Company
Operation affected: Aviation: General aviation
Date, status, type
Date: 03 May 2013
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Safety Advisory Notice
  Proactive Action
Issue, description, who it affects
Issue: AI-2011-150-SI-04Aircraft hopper markings or other level indicators not updated when hopper is modified
Number: AI-2011-150-SI-04
Description: AI-2011-150-SI-04:Aircraft operations with an enlarged hopper but no associated recalibration of the hopper level sight gauge increased the potential for operations at an uncertain aircraft operating weight, and therefore risk of operations in excess of the published aircraft limitations.
Who it affects: Aerial work industry
Issue owner: Operators of M18 Dromader aircraft
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Apr 2013
Status: Partially addressed
Issue, description, who it affects
Issue: AI-2011-150-SI-03Required modifications for M18 aircraft under Supplemental Type Certificate SVA521
Number: AI-2011-150-SI-03
Description: AI-2011-150-SI-03:There was limited assurance that M18 and M18A Dromader aircraft incorporating Supplemental Type Certificate SVA521 would exhibit acceptable handling and performance characteristics if not fitted with vortex generators and M18B standard elevators, in particular that the risk of longitudinal instability had been reliably addressed.
Who it affects: Aerial work industry
Issue owner: Rebel Ag
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Apr 2013
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AI-2011-150-SI-02Information for M18 agricultural operations at weights between 4,200 kg and 5,300 kg
Number: AI-2011-150-SI-02
Description: AI-2011-150-SI-02:There was a potential, depending on the supplements that were incorporated in an aircraft’s flight manual, for pilots and/or operators to apply incorrect operational limitations to agricultural operations in M18 and M18A Dromader aircraft at weights between 4,200 kg and 5,300 kg. This increased the risk of their inconsistent application ...
Who it affects: Aerial work industry
Issue owner: Rebel Ag
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Apr 2013
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AI-2011-150-SI-01Adherence to M18 flight limitations under Supplemental Type Certificate SVA521
Number: AI-2011-150-SI-01
Description: AI-2011-150-SI-01:M18 Dromader aircraft were being operated in the agricultural role at weights for which a 15° bank angle limitation had effect, whereas the nature of agricultural operations increased the risk of pilots exceeding that limitation.
Who it affects: Aerial work industry
Issue owner: Rebel Ag
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Apr 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2013-055-SI-01Fitment of rubber, bladder-type fuel tanks to R44 helicopters
Number: AO-2013-055-SI-01
Description: AO-2013-055-SI-01:Accidents involving Robinson R44 helicopters without bladder-type tanks fitted result in a significantly higher proportion of post-impact fires than for other similar helicopter types. In addition, the existing Australian regulatory arrangements were not sufficient to ensure all R44 operators and owners complied with the manufacturer's Service Bulletin SB-78B and fitted ...
Who it affects: All owners and operators of R44 helicopters
Issue owner: Civil Aviation Safety Authority (CASA)
Operation affected: Aviation: General aviation
Date, status, type
Date: 27 Mar 2013
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2011-090-SI-01No systematic risk assessment for reduced controller training
Number: AO-2011-090-SI-01
Description: AO-2011-090-SI-01:There was no requirement for a systematic risk assessment to be conducted and documented when the planned amount of training for a controller was reduced.
Who it affects: All Airservices Australia air traffic controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 06 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-159-SI-01Dash 8 propeller system design
Number: AO-2011-159-SI-01
Description: AO-2011-159-SI-01:A significant number of DHC-8-100, -200 and -300 series aircraft did not have a means of preventing inadvertent or intentional movement of power levers below the flight idle gate in flight, or a means to prevent such movement resulting in a loss of propeller speed control.
Who it affects: The aircraft operator
Issue owner: Bombardier Aerospace
Operation affected: Aviation: Other
Date, status, type
Date: 25 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-159-SI-02Training for beta warning horn
Number: AO-2011-159-SI-02
Description: AO-2011-159-SI-02:Many DHC-8 pilots were not made aware of the sound of the beta warning horn during their training.
Who it affects: Australian Dash 8 100, 200 and 300 series aircraft operators
Issue owner: QantasLink
Operation affected: Aviation: Air transport
Date, status, type
Date: 25 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-005-SI-01Dash 8-100 Power lever design issue
Number: AO-2012-005-SI-01
Description: AO-2012-005-SI-01:The first 39 manufactured DHC-8-100 aircraft had a design problem such that, if the friction control was wound to the full out (friction off) position, the flight idle gate was ineffective in reducing the likelihood of pilots inadvertently moving the power levers below flight idle in flight.
Who it affects: Operators of Dash 8 100 series aircraft with serial numbers from 001 to 039.
Issue owner: Bombardier Aerospace
Operation affected: Aviation: Other
Date, status, type
Date: 12 Feb 2013
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2011-147-SI-01Local procedure intent and understanding
Number: AO-2011-147-SI-01
Description: AO-2011-147-SI-01:The Cairns air traffic control procedures on the management of missed approaches and the management of successive arriving aircraft were unclear in intent and function, increasing the risk of their incorrect application.
Who it affects: All Cairns based Airservices Australia air traffic controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 04 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-147-SI-02Cairns air traffic control procedures
Number: AO-2011-147-SI-02
Description: AO-2011-147-SI-02:The Cairns air traffic control procedures that defined a minimum spacing of 5 NM to be established when there were no departures (when the cloud base is less than 1,000 ft and/or visibility is less than 2,000 m) were inadequate to assure separation during a missed approach event and may ...
Who it affects:
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 04 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-147-SI-03Cairns missed approach procedure note
Number: AO-2011-147-SI-03
Description: AO-2011-147-SI-03:The missed approach procedure note on the Cairns runway 15 instrument landing system (ILS) or localiser (LOC) approach chart may inadvertently influence a pilot to commence a turn on the missed approach procedure prior to the published missed approach point.
Who it affects:
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 04 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-043-SI-01Guidance material in Civil Aviation Advisory Publication
Number: AO-2010-043-SI-01
Description: AO-2010-043-SI-01:Section 4 of Civil Aviation Advisory Publication (CAAP) 5.23-2(0), Multi engine Aeroplane Operations and Training of July 2007 did not contain sufficient guidance material to support the flight standard in Appendix A subsection 1.2 of the CAAP relating to Engine Failure in the Cruise.
Who it affects: Flight crews
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 20 Dec 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-062-SI-01Wear of the interlocking shrouds.
Number: AO-2011-062-SI-01
Description: AO-2011-062-SI-01:Wear of the interlocking shrouds of the intermediate-pressure turbine blades had the potential to reduce the dampening effects of the feature, and may have led to the development of conditions suitable for fatigue cracking of the IP turbine blades.
Who it affects: Engine manufacturer, operators and maintainers of Rolls-Royce RB211-524 engines
Issue owner: Rolls Royce
Operation affected: Aviation: Maintenance
Date, status, type
Date: 19 Dec 2012
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2011-070-SI-01Data integrity system
Number: AO-2011-070-SI-01
Description: AO-2011-070-SI-01:The operator’s lack of awareness of the data providers’ assumption that the operator was complying with DO-200A Standards for Processing Aeronautical Data, which was not mandated in Australia, meant that the quality of the data was not assured.
Who it affects:
Issue owner: Tiger Airways Australia Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Nov 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-070-SI-02Database anomaly acquittal
Number: AO-2011-070-SI-02
Description: AO-2011-070-SI-02:The inconsistent application of the operator’s safety management system to the identification and rectification of database anomalies, and intermittent notification of these anomalies to crews increased the risk of inadvertent flight crew non compliance with published instrument approach procedures.
Who it affects:
Issue owner: Tiger Airways Australia Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Nov 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-033-SI-01Fatigue management
Number: AO-2011-033-SI-01
Description: AO-2011-033-SI-01:The operator had limited controls in place to manage the fatigue risk associated with early starts.
Who it affects: The operator’s flight crew
Issue owner: Flightech Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 10 Oct 2012
Status: No longer relevant
Issue, description, who it affects
Issue: AO-2009-072-SI-01Fuel planning and en route decision-making
Number: AO-2009-072-SI-01
Description: AO-2009-072-SI-01:The available guidance on fuel planning and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 30 Aug 2012
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2009-072-SI-02Oversight of the flight and its planning
Number: AO-2009-072-SI-02
Description: AO-2009-072-SI-02:The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not effectively minimise the risks associated with aeromedical operations to remote islands.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 30 Aug 2012
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2011-088-SI-01Ineffective corrosion protection of Main Rotor Gearbox
Number: AO-2011-088-SI-01
Description: AO-2011-088-SI-01:Paint application to the main rotor gearbox, gear carrier did not effectively protect the part from corrosion resulting from gearbox water ingress.
Who it affects: Operators of Robinson R44 helicopters
Issue owner: Robinson Helicopter Co
Operation affected: Aviation: Other
Date, status, type
Date: 27 Aug 2012
Status: Safety action pending
Issue, description, who it affects
Issue: AO-2011-127-SI-01Ambiguity in documentation
Number: AO-2011-127-SI-01
Description: AO-2011-127-SI-01:Differences in the traffic alert phraseology between the Manual of Air Traffic Services and Aeronautical Information Publication increased the risk of non-standard advice being provided by the controller to the pilot of the G-IV during the compromised separation recovery.
Who it affects: All air traffic controllers and pilots
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 31 Jul 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-082-SI-01Dromader weight and balance
Number: AO-2011-082-SI-01
Description: AO-2011-082-SI-01:The aircraft's centre of gravity varied significantly with hopper weight and could exceed both the forward and aft limits at different times during a flight.
Who it affects: Operators of PZL Mielec M18 Dromader aircraft using STC SVA521
Issue owner: Owner of the supplemental type certificate
Operation affected: Aviation: General aviation
Date, status, type
Date: 08 Jun 2012
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2010-104-SI-01Melbourne speed restrictions
Number: AO-2010-104-SI-01
Description: AO-2010-104-SI-01:The Auto Release procedures at Melbourne Airport allowed for aircraft to be departed at or close to the separation minima, with no controls in place to ensure aircraft would maintain a minimum speed and flight crews would advise air traffic control if the speed could not be achieved.
Who it affects: All flight operations in Class C airspace
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 02 May 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-016-SI-01Self-locking nut failure
Number: AO-2011-016-SI-01
Description: AO-2011-016-SI-01:A number of self-locking nuts from other aircraft, of the same specification as that used to secure safety-critical fasteners in VH-HFH, were identified to have cracked due to hydrogen embrittlement.
Who it affects: Owners and operators of Robinson Helicopters
Issue owner: Robinson Helicopter Company
Operation affected: Aviation: General aviation
Date, status, type
Date: 30 Apr 2012
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2011-016-SI-02Bladder-type fuel tank retrofit
Number: AO-2011-016-SI-02
Description: AO-2011-016-SI-02:A significant number of R44 helicopters, including VH-HFH, were not fitted with bladder-type fuel tanks and the other modifications detailed in the manufacturer's service bulletin 78 that were designed to provide improved resistance to post-impact fuel leaks.
Who it affects: Owners and operators of Robinson Helicopters
Issue owner: Robinson Helicopter Company
Operation affected: Aviation: General aviation
Date, status, type
Date: 30 Apr 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-066-SI-01Turbine blade fatigue endurance limit
Number: AO-2010-066-SI-01
Description: AO-2010-066-SI-01:High service time stage-2 LP turbine blades were susceptible to a reduction in fatigue endurance as a result of vibratory stresses sustained during operation at speeds close to the maximum.
Who it affects: Operators of aircraft fitted with Rolls-Royce RB211-524 engines
Issue owner: Rolls Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Apr 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-066-SI-02Two-piece LP turbine bearing susceptible to abnormal loads
Number: AO-2010-066-SI-02
Description: AO-2010-066-SI-02:LP turbine support bearings (part numbers LK30313 and UL29651) showed increased susceptibility to breakdown and collapse under vibratory stress conditions associated with LP turbine blade release.
Who it affects: Operators of aircraft fitted with Rolls-Royce RB211-524 engines
Issue owner: Rolls Royce
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Apr 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2012-021-SAN-001R44 helicopter all-aluminium fuel tanks
Number: AO-2012-021-SAN-001
Description: AO-2012-021-SAN-001:The Australian Transport Safety Bureau encourages all operators and owners of R44 helicopters that are fitted with all-aluminium fuel tanks to note the circumstances of this accident as detailed in this preliminary report. It is suggested that those operators and owners actively consider replacing these tanks with bladder-type fuel tanks ...
Who it affects: Owners and operators of R44 helicopters
Issue owner: Robinson Helicopter Company
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Mar 2012
Status: Partially addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2011-011-SI-01Compromised separation recovery training
Number: AO-2011-011-SI-01
Description: AO-2011-011-SI-01:The Department of Defence’s air traffic controllers had not received training in compromised separation recovery techniques.
Who it affects: All Department of Defence air traffic controllers
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 07 Mar 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-011-SI-02Disabling of Australian Defence Air Traffic System conflict alerts
Number: AO-2011-011-SI-02
Description: AO-2011-011-SI-02:An important alerting function within the Australian Defence Air Traffic System had been disabled at Williamtown to prevent nuisance alerts.
Who it affects: All RAAF Base Williamtown based Department of Defence air traffic controllers
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 07 Mar 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-011-SI-03Air traffic control procedures at Williamtown
Number: AO-2011-011-SI-03
Description: AO-2011-011-SI-03:The Williamtown air traffic control procedures did not clearly define the separation responsibilities and coordination requirements between the Approach sectors for departing aircraft.
Who it affects: All RAAF Base Williamtown based Department of Defence air traffic controllers
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 07 Mar 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-027-SI-01Flight crew proficiency
Number: AO-2010-027-SI-01
Description: AO-2010-027-SI-01:The aircraft operator’s flight crews were probably not adequately equipped to manage the vertical profile of non-precision approaches in other than autopilot managed mode.
Who it affects:
Issue owner: AirAsia X
Operation affected: Aviation: Air transport
Date, status, type
Date: 10 Feb 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-081-SI-01Load Sheet layout
Number: AO-2010-081-SI-01
Description: AO-2010-081-SI-01:The presentation on the aircraft load sheet of the zero fuel weight immediately below the operating weight, increased the risk of selecting the inapropriate figure for flight management system data entry.
Who it affects:
Issue owner: Cobham Aviation Services Australia
Operation affected: Aviation: Air transport
Date, status, type
Date: 09 Feb 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-081-SI-02Take-off weight check procedure
Number: AO-2010-081-SI-02
Description: AO-2010-081-SI-02:The operator's procedure for confirming the validity of the flight management system generated take-off weight did not place sufficient emphasis on the check against the load sheet.
Who it affects:
Issue owner: Cobham Aviation Services Australia
Operation affected: Aviation: Air transport
Date, status, type
Date: 09 Feb 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-081-SI-03Validation of landing weight
Number: AO-2010-081-SI-03
Description: AO-2010-081-SI-03:The operators procedures did not include a validation check of the landing weight generated by the flight management system which resulted in lack of assurance that the approach and landing speeds were valid.
Who it affects:
Issue owner: Cobham Aviation Services Australia
Operation affected: Aviation: Air transport
Date, status, type
Date: 09 Feb 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-081-SI-04Recurrent training
Number: AO-2010-081-SI-04
Description: AO-2010-081-SI-04:The operators recurrent simulator training did not address the recovery from a stall or stick shaker activation such that the ongoing competency of their flight crew was not assured.
Who it affects:
Issue owner: Cobham Aviation Services Australia
Operation affected: Aviation: Air transport
Date, status, type
Date: 09 Feb 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-012-SI-02Cross-crew qualification and mixed fleet flying
Number: AO-2009-012-SI-02
Description: AO-2009-012-SI-02:The available Cross Crew Qualification and Mixed Fleet Flying guidance did not address how flight crew might form an expectation, or conduct a ‘reasonableness' check, of the speed/weight relationship for their aircraft during takeoff.
Who it affects: Flight crews
Issue owner: Airbus, Flight Safety Foundation, International Air Transport Association
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Partially addressed
Type: Safety Advisory Notice
  Safety Advisory Notice
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-070-SI-01Air data inertial reference unit (ADIRU) failure
Number: AO-2008-070-SI-01
Description: AO-2008-070-SI-01:One of the aircraft’s three air data inertial reference units (ADIRU 1) exhibited a data-spike failure mode, during which it transmitted a significant amount of incorrect data on air data parameters to other aircraft systems, without flagging that this data was invalid. The invalid data included frequent spikes in angle ...
Who it affects: All operators of aircraft fitted with LTN-101 ADIRUs
Issue owner: Northrop Grumman Corporation
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-070-SI-02Angle or attack processing algorithm
Number: AO-2008-070-SI-02
Description: AO-2008-070-SI-02:There was a limitation in the algorithm used by the A330/A340 flight control primary computers (FCPCs) for processing angle of attack (AOA) data. This limitation meant that, in a very specific situation, multiple spikes in AOA from only one of the three ADIRUs could result in a nose-down elevator command.
Who it affects: All operators of A330/A340 aircraft
Issue owner: Airbus
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-070-SI-03Air data inertial reference unit (ADIRU) fault detection
Number: AO-2008-070-SI-03
Description: AO-2008-070-SI-03:For the data-spike failure mode, the built-in test equipment of the LTN 101 air data inertial reference unit was not effective, for air data parameters, in detecting the problem, communicating appropriate fault information, and flagging affected data as invalid.
Who it affects: All operators of aircraft fitted with LTN-101 ADIRUs
Issue owner: Northrop Grumman Corporation
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-070-SI-04Flight control primary computer design
Number: AO-2008-070-SI-04
Description: AO-2008-070-SI-04:When developing the A330/A340 flight control primary computer software in the early 1990s, the aircraft manufacturer’s system safety assessment and other development processes did not fully consider the potential effects of frequent spikes in the data from an air data inertial reference unit.
Who it affects: All operators of A330/A340 aircraft
Issue owner: Airbus
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-070-SI-05Seat belts usage
Number: AO-2008-070-SI-05
Description: AO-2008-070-SI-05:Although passengers are routinely reminded to keep their seat belts fastened during flight whenever they are seated, a significant number of passengers have not followed this advice. At the time of the first in-flight upset, more than 60 of the 303 passengers were seated without their seat belts fastened.
Who it affects: All aircraft passengers
Issue owner: All high capacity operators
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-070-SI-06Limited evaluation of design process
Number: AO-2008-070-SI-06
Description: AO-2008-070-SI-06:In recent years there have been developments in guidance materials for system development processes and research into new approaches for system safety assessments. However, there has been limited research that has systematically evaluated how design engineers and safety analysts conduct their evaluations of systems, and how the design of their ...
Who it affects: All aircraft operators
Issue owner: All high capacity operators
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Not addressed
Issue, description, who it affects
Issue: AO-2008-070-SI-07Single event effect general risk to avionics
Number: AO-2008-070-SI-07
Description: AO-2008-070-SI-07:Single event effects (SEE) have the potential to adversely affect avionics systems that have not been specifically designed to be resilient to this hazard. There were no specific certification requirements for SEE, and until recently there was no formal guidance material available for addressing SEE during the design process.
Who it affects: All aircraft operators
Issue owner: All high capacity operators
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Partially addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-070-SI-08Air data inertial reference unit (ADIRU) susceptibility to single event effects
Number: AO-2008-070-SI-08
Description: AO-2008-070-SI-08:The LTN-101 air data inertial reference unit (ADIRU) model had a demonstrated susceptibility to single event effects (SEE). The consideration of SEE during the design process was consistent with industry practice at the time the unit was developed, and the overall fault rates of the ADIRU were within the relevant ...
Who it affects: All operators of aircraft fitted with LTN-101 ADIRUs
Issue owner: Northrop Grumman Corporation
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-070-SI-09Line-replaceable units problem tracking
Number: AO-2008-070-SI-09
Description: AO-2008-070-SI-09:Industry practices for tracking faults or performance problems with line-replaceable units are limited, unless the units are removed for examination. Consequently, the manufacturers of aircraft equipment have incomplete information for identifying patterns or trends that can be used to improve the safety, availability or reliability of the units.
Who it affects: All aircraft operators and maintenance organisations
Issue owner: All high capacity operators
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Not addressed
Issue, description, who it affects
Issue: AO-2008-070-SI-10Research into passenger seat belt compliance
Number: AO-2008-070-SI-10
Description: AO-2008-070-SI-10:There has been very little research conducted into the factors influencing passengers’ use of seat belts when the seat-belt sign is not illuminated, and the effectiveness of different techniques to increase the use of seat belts.
Who it affects: All aircraft passengers
Issue owner: All high capacity operators
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Not addressed
Issue, description, who it affects
Issue: AO-2008-070-SI-11Instructions to wear seat belts in cruise
Number: AO-2008-070-SI-11
Description: AO-2008-070-SI-11:Although passengers are routinely advised after takeoff to wear their seat belts when seated, this advice typically does not reinforce how the seat belts should be worn.
Who it affects: All aircraft passengers
Issue owner: All high capacity operators
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 Dec 2011
Status: Not addressed
Issue, description, who it affects
Issue: AO-2009-012-SI-01Take-off decision making philosophy
Number: AO-2009-012-SI-01
Description: AO-2009-012-SI-01:The existing take-off certification standards, which were based on the attainment of the take-off reference speeds, and flight crew training that was based on monitoring of and responding to those speeds, did not provide crews a means to detect degraded take-off acceleration.
Who it affects: Flight crews
Issue owner: US Federal Aviation Administration
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Dec 2011
Status: Safety action pending
Type: Recommendation
  Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-012-SI-03Flight plan document design
Number: AO-2009-012-SI-03
Description: AO-2009-012-SI-03:The lack of a designated position in the pre-flight documentation to record the green dot speed precipitated a number of informal methods of recording that value, lessening the effectiveness of the green dot check within the loadsheet confirmation procedure.
Who it affects: The operator’s flight crew
Issue owner: Emirates
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-012-SI-04Distraction management processes
Number: AO-2009-012-SI-04
Description: AO-2009-012-SI-04:The operator’s training and processes in place to enable flight crew to manage distractions during the pre-departure phase did not minimise the effect of distraction during safety critical tasks.
Who it affects: The operator’s flight crew
Issue owner: Emirates
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-012-SI-05Flight Data Recorder rack
Number: AO-2009-012-SI-05
Description: AO-2009-012-SI-05:The failure of the digital flight data recorder (DFDR) rack during the tail strike prevented the DFDR from recording subsequent flight parameters.
Who it affects: Operators of A340 aircraft
Issue owner: Airbus
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-084-SI-01Recording of service life factors
Number: AO-2008-084-SI-01
Description: AO-2008-084-SI-01:A number of operators of the PZL M-18 Dromader aircraft had not applied the appropriate service life factors to the aircraft’s time in service for operations conducted with take-off weights greater than 4,700 kg, as required by the aircraft’s service documentation. Hence the operators could not be assured that their ...
Who it affects: Pilots of M18 Dromader aircraft
Issue owner: Civil Aviation Safety Authority and Operators of M18 Dromader aircraft
Operation affected: Aviation: General aviation
Date, status, type
Date: 16 Dec 2011
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-084-SI-02CASA exemptions do not provide adequate level of safety
Number: AO-2008-084-SI-02
Description: AO-2008-084-SI-02:Operation of the M-18A in accordance with Civil Aviation Safety Authority exemptions EX56/07 and EX09/07 at weights in excess of the basic Aircraft Flight Manual maximum take-off weight (MTOW), up to the MTOW listed on the Type Certificate Data Sheet, may not provide the same level of safety intended by ...
Who it affects: Pilots conducting agricultural operations
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 16 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-076-SI-01Organisational Operations Manual and Safety Management Systems
Number: AO-2010-076-SI-01
Description: AO-2010-076-SI-01:The lack of a requirement for a charter-specific risk assessment in this case meant that the risks associated with the charter were not adequately addressed.
Who it affects: Charter operators
Issue owner: Wayport Pty Ltd
Operation affected: Aviation: Air transport
Date, status, type
Date: 01 Dec 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-045-SI-01Commercial balloon procedural and guidance framework
Number: AO-2011-045-SI-01
Description: AO-2011-045-SI-01:The procedural and guidance framework for commercial balloon operations generally, did not provide a high level of assurance in regard to the safe conduct of low flying.
Who it affects:
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 21 Nov 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-006-SI-01Society of Automotive Engineers specification
Number: AO-2010-006-SI-01
Description: AO-2010-006-SI-01:The Society of Automotive Engineers specification AS7477 was ambiguous in relation to the requirement to cold roll the head-to-shank fillet radius of MS9490-34 bolts.
Who it affects: Users of MS9490-34 bolts
Issue owner: Society of Automotive Engineers
Operation affected: Aviation: Other
Date, status, type
Date: 17 Nov 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-006-SI-02Non-cold rolled bolts into service
Number: AO-2010-006-SI-02
Description: AO-2010-006-SI-02:A number of non-cold rolled bolts were installed on PT6A-67 series engines during manufacture and overhaul
Who it affects: Users of PT6A-67 engines
Issue owner: Pratt and Whitney (Canada)
Operation affected: Aviation: Other
Date, status, type
Date: 17 Nov 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-081-SI-01Maintenance for repetitve lift missions
Number: AO-2009-081-SI-01
Description: AO-2009-081-SI-01:The scheduled maintenance requirements for ex-military UH-1 series helicopters may not adequately address the increased risk of fatigue failures associated with repetitive heavy lifting operations that were not considered in the original design fatigue calculations.
Who it affects: All operators and maintainers of ex-military helicopters engaged in repetitive lift missions
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Maintenance
Date, status, type
Date: 11 Nov 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-066-SI-01Inconsistent monitoring messages in company documentation
Number: AO-2009-066-SI-01
Description: AO-2009-066-SI-01:The conflicting requirements and definitions in the operator’s publications in relation to the pilot not flying role had the potential to diminish the importance of monitoring as an essential element in an aircraft’s safe operation.
Who it affects: Qantas Airways
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-066-SI-02Correlation between flight data and incident reports
Number: AO-2009-066-SI-02
Description: AO-2009-066-SI-02:There was no correlation between the results of the operator’s Flight Operational Quality Assurance and Air Safety Incident Report investigations.
Who it affects: Qantas Airways
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-066-SI-03Monitoring of landing gear through Flight Operational Quality Assurance
Number: AO-2009-066-SI-03
Description: AO-2009-066-SI-03:There were no soft and hard triggers in the operator’s Flight Operational Quality Assurance system to monitor the selection of the aircraft’s landing gear during an approach.
Who it affects: Qantas Airways
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 18 Oct 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-027-SI-01Windshield terminal block failure
Number: AO-2009-027-SI-01
Description: AO-2009-027-SI-01:Windshields manufactured with terminal block fittings containing polysulfide sealant (PR1829) have been shown to be predisposed to premature overheating failure that could lead to the development of a localised fire.
Who it affects: Operators of Airbus A330 aircraft
Issue owner: Airbus Industrie
Operation affected: Aviation: Other
Date, status, type
Date: 07 Oct 2011
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Number: AO-2009-044-SAN-068
Description: AO-2009-044-SAN-068: The Australian Transport Safety Bureau encourages all operators of single-pilot, turbine-powered, pressurised aircraft to consider the installation of an aural cabin altitude pressure warning system that operates separately to their aircraft's visual warning system.
Who it affects: All operators of single-pilot, turbine-powered, pressurised aircraft
Issue owner:
Operation affected:
Date, status, type
Date: 21 Sep 2011
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2009-044-SI-01Cabin Altitude Warning switc wiring diagram
Number: AO-2009-044-SI-01
Description: AO-2009-044-SI-01:The cabin altitude warning pressure switch maintenance manual wiring diagram did not provide a clear indication of the wiring connections for the superseded switch.
Who it affects: Owners, operators and maintenance venues for Beech King Air 90 aircraft
Issue owner: Raytheon Aircraft Co
Operation affected: Aviation: Maintenance
Date, status, type
Date: 21 Sep 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-044-SI-02Replacement of cabin altitude warning switch
Number: AO-2009-044-SI-02
Description: AO-2009-044-SI-02:The aircraft maintenance manuals did not include the operating specifications of the replacement cabin altitude warning pressure switch hampering the required verification of switch serviceabilty.
Who it affects: Owners, operators and maintenance venues for Beech King Air 90 aircraft
Issue owner: Raytheon Aircraft Co
Operation affected: Aviation: Maintenance
Date, status, type
Date: 21 Sep 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2011-055-SI-01Emergency Locator Transmitter re-programming risk
Number: AO-2011-055-SI-01
Description: AO-2011-055-SI-01:There were only subtle cues to the fitment of programming dongles and no requirement to test Emergency Locator Transmitter (ELT) programming after installation, increasing the risk of inadvertent and undetected ELT re-programming and a less effective search and rescue response.
Who it affects:
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Maintenance
Date, status, type
Date: 08 Aug 2011
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-069-SI-01Turbine blade material susceptible to creep rupture
Number: AO-2009-069-SI-01
Description: AO-2009-069-SI-01:Material characteristics of some the LPT blades installed in engine 858322 were consistent with a raw material manufacturing cast that had previously been identified as being susceptible to creep rupture
Who it affects: Operators of aircraft fitted with CFM56 engines
Issue owner: CFM International
Operation affected: Aviation: Other
Date, status, type
Date: 20 Jul 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-026-SI-01Independent fuel check procedures
Number: AO-2009-026-SI-01
Description: AO-2009-026-SI-01:The operator did not have a procedure in place to ensure independent cross-checking of the helicopter's fuel quantity.
Who it affects: The aircraft operator
Issue owner: James Technologies (Aviation) Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 15 Jul 2011
Status: No longer relevant
Issue, description, who it affects
Number: AO-2011-060-SAN-001
Description: AO-2011-060-SAN-001:The Australian Transport Safety Bureau encourages all operators of R22 helicopters, and organisations performing installation, inspection, and maintenance activities on the drive belts of R22 helicopters to note the circumstances detailed in this preliminary report. The ATSB reinforces the need for continued vigilance by operators and maintenance organisations during the ...
Who it affects: Operators of R22 helicopters
Issue owner:
Operation affected:
Date, status, type
Date: 06 Jul 2011
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2009-080-SI-01Compromised separation training
Number: AO-2009-080-SI-01
Description: AO-2009-080-SI-01:The controller had not received training in compromised separation recovery techniques.
Who it affects: All Airservices Australia air traffic controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 24 Jun 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-080-SI-02Ambiguity in documentation
Number: AO-2009-080-SI-02
Description: AO-2009-080-SI-02:Ambiguity existed between the Manual of Air Traffic Services and the Aeronautical Information Publication in relation to the assignment of non-standard cruising levels and the definition of an ‘operational requirement’.
Who it affects: All Airservices Australia en route air traffic controllers and All flight crews operating in controlled airspace
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 24 Jun 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-059-SI-01Airspace design for strategic separation
Number: AO-2008-059-SI-01
Description: AO-2008-059-SI-01:Moorabbin GAAP airspace design did not assure lateral or vertical strategic separation between traffic flows. This increased the risk of a mid-air collision.
Who it affects: Pilots flying in D airspace at a capital city general aviation airport
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 31 May 2011
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-059-SI-02Action related to review of GAAP operations
Number: AO-2008-059-SI-02
Description: AO-2008-059-SI-02:There was no evidence of any action taken by Airservices to address safety recommendations related to a review of Key Performance Indicators (KPI’s) of GAAP operations.
Who it affects: Pilots flying in D airspace at a capital city general aviation airport
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 31 May 2011
Status:
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-034-SI-01Quarantine procedures
Number: AO-2009-034-SI-01
Description: AO-2009-034-SI-01:There was no procedure or guidance for the segregation of freight that was rejected during loading.
Who it affects:
Issue owner: Jetstar Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 May 2011
Status:
Issue, description, who it affects
Issue: AO-2009-034-SI-02Ground handling emergency communication procedures
Number: AO-2009-034-SI-02
Description: AO-2009-034-SI-02:The aircraft operator did not provide procedures that allowed ground handling personnel to communicate effectively with the flight crew in the event of an urgent operational matter occurring after pushback.
Who it affects:
Issue owner: Jetstar Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 May 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-026-SI-01Endorsement training
Number: AO-2008-026-SI-01
Description: AO-2008-026-SI-01:The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual , with the result that the pilot’s competence and ultimately, safety of the operation could not be assured.
Who it affects: The operator’s flight crew
Issue owner: Airtex Air Services Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 16 May 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-077-SI-01Low visibility risk at helicopter landing area
Number: AO-2009-077-SI-01
Description: AO-2009-077-SI-01:The helicopter landing area was occasionally subjected to rapidly-moving fog or low cloud that increased the risk of flights under the visual flight rules encountering instrument meteorological conditions.
Who it affects: NSW National Parks and Wildlife Service and helicopter operators at the Dorrigo facility.
Issue owner: National Parks and Wildlife Service
Operation affected: Aviation: General aviation
Date, status, type
Date: 11 May 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Number: AO-2009-073-SAN-048
Description: AO-2009-073-SAN-048:The Australian Transport Safety Bureau advises that all operators of Eurocopter AS350 aircraft should consider the implications of this safety issue and take action where considered appropriate. In particular, operators are encouraged to review the appropriate sections of the aircraft maintenance manual with regard to cargo door flushness and give ...
Who it affects: Operators of Eurocopter AS350 aircraft
Issue owner:
Operation affected:
Date, status, type
Date: 11 Apr 2011
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2009-073-SI-01Cargo door seal exceeds flushness tolerance
Number: AO-2009-073-SI-01
Description: AO-2009-073-SI-01:Installation of new cargo door seals resulted in the cargo door being held outside of the flushness requirement specified in the aircraft maintenance manual
Who it affects: Operators of Eurocopter AS350 helicopters
Issue owner: Helicopter owner
Operation affected: Aviation: Maintenance
Date, status, type
Date: 11 Apr 2011
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2010-008-SI-01Buildings dimensions and location
Number: AO-2010-008-SI-01
Description: AO-2010-008-SI-01:Two buildings were constructed north of the runway 12 threshold at a height and position that could generate turbulence affecting the approach, threshold and touchdown areas of the runway under some wind conditions.
Who it affects: The Canberra Airport operator and all flight operations to runway 12, at Canberra Airport
Issue owner: Canberra Airport Operator
Operation affected: Aviation: Airports
Date, status, type
Date: 05 Apr 2011
Status:
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-008-SI-02Wind Modelling Criteria
Number: AO-2010-008-SI-02
Description: AO-2010-008-SI-02:There were no criteria for assessing the potential wind impact of aerodrome building developments on aircraft operations.
Who it affects: All airport operators
Issue owner: Department of Infrastructure, Transport, Regional Development and Local Government
Operation affected: Aviation: Other
Date, status, type
Date: 05 Apr 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-008-SI-03Airport Wind Modelling during building development
Number: AO-2010-008-SI-03
Description: AO-2010-008-SI-03:The limited consideration of the potential wind impact of the two buildings to the north of runway 12 during northerly wind conditions has resulted in continued operations to that runway in those conditions without any alert to affected pilots about the associated risk.
Who it affects: The Canberra Airport operator and all flight operations to runway 12, at Canberra Airport
Issue owner: Canberra Airport Pty Ltd
Operation affected: Aviation: Airports
Date, status, type
Date: 05 Apr 2011
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AE-2009-050-SI-01Emergency procedures for Visual flight in IMC
Number: AE-2009-050-SI-01
Description: AE-2009-050-SI-01:The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
Who it affects:
Issue owner: Aircraft operator
Operation affected: Aviation: Air transport
Date, status, type
Date: 31 Mar 2011
Status: Adequately addressed
Issue, description, who it affects
Issue: AE-2009-050-SI-04Flight recorders
Number: AE-2009-050-SI-04
Description: AE-2009-050-SI-04:The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
Who it affects:
Issue owner: Papua New Guinea Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 31 Mar 2011
Status:
Issue, description, who it affects
Issue: AE-2009-050-SI-03CASA medical director
Number: AE-2009-050-SI-03
Description: AE-2009-050-SI-03:There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG) that could enhance the administration of the PNG aviation medical regime.
Who it affects:
Issue owner: Papua New Guinea Civil Aviation Safety Authority
Operation affected: Aviation: Other
Date, status, type
Date: 31 Mar 2011
Status:
Issue, description, who it affects
Issue: AE-2009-050-SI-02Mandatory occurrence reporting
Number: AE-2009-050-SI-02
Description: AE-2009-050-SI-02:The lack of a reliable mandatory occurrence reporting arrangement minimised the likelihood of an informed response to Papua New Guinea specific safety risks.
Who it affects:
Issue owner: Papua New Guinea Civil Aviation Safety Authority
Operation affected: Aviation: Other
Date, status, type
Date: 31 Mar 2011
Status: Adequately addressed
Issue, description, who it affects
Issue: Robinson R44 helicopter hydraulic-boost systems
Description: The Australian Transport Safety Bureau encourages all operators of hydraulic system‑equipped R44 helicopters, and organisations performing inspection, testing, maintenance and repair activities on the flight control systems of those helicopters, to note the circumstances detailed in this preliminary report. It is suggested that those operators and maintenance organisations consider inspecting ...
Who it affects: Robinson R44 operators and maintenance organisations
Issue owner:
Operation affected:
Date, status, type
Date: 18 Mar 2011
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2009-007-SI-01Takeoff procedures
Number: AO-2009-007-SI-01
Description: AO-2009-007-SI-01:The operator did not have procedures to assist the crew to ensure that the aircraft was lined up on the runway centreline in preparation for takeoff.
Who it affects: Operator and operator’s flight crew
Issue owner: QantasLink
Operation affected: Aviation: Air transport
Date, status, type
Date: 28 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-065-SI-01Pitot probe design specifications
Number: AO-2009-065-SI-01
Description: AO-2009-065-SI-01:Although the pitot probes fitted to A330/A340 aircraft met relevant design specifications, these specifications were not sufficient to prevent the probes from being obstructed with ice during some types of environmental conditions that the aircraft could encounter.
Who it affects: All owners and operators of Airbus A330/A340 aircraft
Issue owner: European Aviation Safety Agency
Operation affected: Aviation: Other
Date, status, type
Date: 27 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-065-SI-02Unreliable airspeed training
Number: AO-2009-065-SI-02
Description: AO-2009-065-SI-02:By the time of the 28 October 2009 occurrence, many of the operator’s A330 flight crew had not received unreliable airspeed training. Such training started being introduced in the operator’s recurrent training program before the occurrence.
Who it affects: The operator’s A330 flight crew
Issue owner: Jetstar Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jan 2011
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-065-SI-03Third party access to Airbus
Number: AO-2009-065-SI-03
Description: AO-2009-065-SI-03:When revising or maintaining its A320 endorsement training program, the third party training provider did not use or have access to current versions of the aircraft manufacturer’s recommended training program.
Who it affects: Pilots undertaking an A320 endorsement
Issue owner: Boeing Training and Flight Services
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jan 2011
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-062-SI-01Landing gear wheel design
Number: AO-2009-062-SI-01
Description: AO-2009-062-SI-01:The post-2005 main landing gear wheel design had shown a susceptibility to fatigue cracking at the inner hub bearing bore shoulder radius.
Who it affects: Boeing 737 landing gear wheel manufacturer, operators and maintainers of Boeing 737 aircraft
Issue owner: Honeywell
Operation affected: Aviation: Other
Date, status, type
Date: 21 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-062-SI-02Inadequate inspection procedures
Number: AO-2009-062-SI-02
Description: AO-2009-062-SI-02:At the time of the last tyre change, crack initiation at the bearing bore shoulder radius was an emerging issue with no requirement for mandatory inspection of this area during a tyre change.
Who it affects: Boeing 737 landing gear wheel manufacturer, operators and maintainers of Boeing 737 aircraft
Issue owner: Honeywell
Operation affected: Aviation: Maintenance
Date, status, type
Date: 21 Jan 2011
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-068-SI-01Requirement to confirm hover reference
Number: AO-2009-068-SI-01
Description: AO-2009-068-SI-01:The operator’s winching procedure did not include the requirement to confirm adequate hover reference existed overhead an intended winch area prior to deploying personnel on the winch.
Who it affects: Helicopter operator
Issue owner: Australian Helicopters Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-068-SI-02Lack of formal task risk management
Number: AO-2009-068-SI-02
Description: AO-2009-068-SI-02:There was no formal risk assessment process in use at the operator’s Horn Island base.
Who it affects: Helicopter operator
Issue owner: Australian Helicopters Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 21 Jan 2011
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-025-SI-01Fuel dipstick methods
Number: AO-2010-025-SI-01
Description: AO-2010-025-SI-01:There was the potential for the incorrect use of the dipstick to result in the over-reading of the fuel quantity.
Who it affects: Owners, operators and pilots of Victa Airtourer aircraft
Issue owner: Airtourer Association
Operation affected: Aviation: General aviation
Date, status, type
Date: 14 Dec 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2010-025-SI-02Aircraft's pilot operating handbook
Number: AO-2010-025-SI-02
Description: AO-2010-025-SI-02:Information contained in the approved flight manual and pilot's operating handbook was not applicable to the engine that was fitted to the aircraft.
Who it affects: Owners, operators and pilots of Victa Airtourer aircraft
Issue owner: Airtourer Association
Operation affected: Aviation: General aviation
Date, status, type
Date: 14 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-025-SI-03Registered Operator's maintenance practices
Number: AO-2010-025-SI-03
Description: AO-2010-025-SI-03:The Registered Operator's maintenance control practices did not ensure compliance with all Airworthiness Directives.
Who it affects: Owners, operators and pilots of Victa Airtourer aircraft
Issue owner: Royal Aero Club of Southern Tasmania
Operation affected: Aviation: Maintenance
Date, status, type
Date: 14 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Number: AO-2008-003-SR-108
Description: AO-2008-003-SR-108:The flight crew quick reference handbook did not include sufficient information for the flight crew to appropriately manage operations on standby power. Action taken by the aircraft operator As a result of this occurrence, the aircraft operator: evaluated the provision of additional formal guidance to 747‑400 flight crew for operations on standby power, ...
Who it affects: Boeing Company
Issue owner:
Operation affected:
Date, status, type
Date: 13 Dec 2010
Original risk: Significant
Status:
Type: Recommendation
Issue, description, who it affects
Number: AO-2008-003-SAN-107
Description: AO-2008-003-SAN-107:The priority level of the battery discharge messages that were provided by the engine indicating and crew alerting system did not accurately reflect the risk presented by the battery discharge status. Action taken by the ATSB During the investigation, the ATSB discussed the background for this safety issue and the associated safety ...
Who it affects: Operators and flight crews of transport category aircraft
Issue owner:
Operation affected:
Date, status, type
Date: 13 Dec 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: AO-2008-003-SR-109
Description: AO-2008-003-SR-109:The United States Federal Aviation Administration regulations and associated guidance material did not fully address the potential harm to flight safety posed by liquid contamination of electrical system units in transport category aircraft. Action taken by the ATSB During the investigation, the ATSB discussed the background for this safety issue and the ...
Who it affects: US Federal Aviation Administration
Issue owner:
Operation affected:
Date, status, type
Date: 13 Dec 2010
Status:
Type: Recommendation
Issue, description, who it affects
Issue: AO-2009-017-SI-01Hazard identification procedures
Number: AO-2009-017-SI-01
Description: AO-2009-017-SI-01:The Aerial Agricultural Association of Australia suggestion that an additional hazard identification check be carried out prior to a cleanup run was not routinely practiced by the pilots, or monitored by the operator.
Who it affects:
Issue owner: Helifarm Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 13 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-017-SI-02Potential to overload helicopter
Number: AO-2009-017-SI-02
Description: AO-2009-017-SI-02:The removal of fluid quantity markings from, and unapproved modifications to the helicopter’s spray tank by the operator increased the risk of overweight operations
Who it affects:
Issue owner: Helifarm Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 13 Dec 2010
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-003-SI-01Maintenance processes did not identify or correct the deterioration of the dripshield
Number: AO-2008-003-SI-01
Description: AO-2008-003-SI-01:Maintenance processes did not identify or correct the deterioration of the drip shield.
Who it affects: Operators of Boeing 747-400 aircraft
Issue owner: Boeing Co
Operation affected: Aviation: Maintenance
Date, status, type
Date: 13 Dec 2010
Status: Partially addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-003-SI-02Floor sealing design
Number: AO-2008-003-SI-02
Description: AO-2008-003-SI-02:The location of the decompression panel and absence of cabin floor sealing above the main equipment centre increased the risk of liquid ingress into the aircraft’s electrical systems.
Who it affects: Operators of Boeing 747-400 aircraft
Issue owner: Boeing Co
Operation affected: Aviation: Other
Date, status, type
Date: 13 Dec 2010
Status: Partially addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-003-SI-03Maintenance processes for corrosion in the generator control units
Number: AO-2008-003-SI-03
Description: AO-2008-003-SI-03:Maintenance processes did not identify or correct the corrosion in the generator control units.
Who it affects: Operators of aircraft fitted with Hamilton Sundstrand Corporation generator or bus control units
Issue owner: Hamilton Sundstrand Corporation
Operation affected: Aviation: Maintenance
Date, status, type
Date: 13 Dec 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-003-SI-04Maintenance processes for drain line heater
Number: AO-2008-003-SI-04
Description: AO-2008-003-SI-04:Maintenance processes did not identify or correct the inoperability of the forward drain line heater.
Who it affects: Operators of Boeing 747-400 aircraft
Issue owner: Boeing Co
Operation affected: Aviation: Maintenance
Date, status, type
Date: 13 Dec 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-003-SI-05Maintenance processes for galley floor sealing
Number: AO-2008-003-SI-05
Description: AO-2008-003-SI-05:Maintenance processes did not identify or correct the deterioration of the galley floor sealing
Who it affects: Operators of Boeing 747-400 aircraft
Issue owner: Qantas Airways
Operation affected: Aviation: Maintenance
Date, status, type
Date: 13 Dec 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-003-SI-06Maintenance for drain lines
Number: AO-2008-003-SI-06
Description: AO-2008-003-SI-06:The galley drain operation and maintenance processes did not adequately prevent blockage and overflow of the aircraft’s drain lines.
Who it affects: Operators of Boeing 747-400 aircraft
Issue owner: Qantas Airways
Operation affected: Aviation: Maintenance
Date, status, type
Date: 13 Dec 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-003-SI-07Design of galley floor sealing
Number: AO-2008-003-SI-07
Description: AO-2008-003-SI-07:The floor sealing around the forward galley was not of sufficient extent to prevent liquids from passing through to the under floor area.
Who it affects: Operators of Boeing 747-400 aircraft
Issue owner: Boeing Company
Operation affected: Aviation: Other
Date, status, type
Date: 13 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-003-SI-08Operator’s documented design objectives
Number: AO-2008-003-SI-08
Description: AO-2008-003-SI-08:The aircraft operator’s documented design objectives did not explicitly require the protection of non-structural systems from liquid contact or ingress.
Who it affects: Qantas Airways
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 13 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-003-SI-09Flight crew quick reference handbook
Number: AO-2008-003-SI-09
Description: AO-2008-003-SI-09:The operator’s flight crew quick reference handbook did not include sufficient information for flight crew to manage the emergency.
Who it affects: Operators of Boeing 747-400 aircraft
Issue owner: Boeing Co
Operation affected: Aviation: Air transport
Date, status, type
Date: 13 Dec 2010
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2008-003-SI-10Fluid protection design guidance
Number: AO-2008-003-SI-10
Description: AO-2008-003-SI-10:The United States Federal Aviation Administration regulations and associated guidance material did not fully address the potential harm to flight safety posed by liquid contamination of electrical system units in transport category aircraft.  
Who it affects: Manufacturers and operators of transport category aircraft
Issue owner: US Federal Aviation Administration
Operation affected: Aviation: Other
Date, status, type
Date: 13 Dec 2010
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2008-003-SI-11Battery discharge message priority design
Number: AO-2008-003-SI-11
Description: AO-2008-003-SI-11:The priority level of the battery discharge messages that were provided by the engine indicating and crew alerting system did not accurately reflect the risk presented by the battery discharge status.
Who it affects: Operators of Boeing 747-400 aircraft
Issue owner: Boeing Co
Operation affected: Aviation: Other
Date, status, type
Date: 13 Dec 2010
Status: Partially addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2008-078-SI-01Appreciation of the significance of transpositions
Number: AO-2008-078-SI-01
Description: AO-2008-078-SI-01:Neither the maintenance provider, nor the helicopter operator appreciated the potential significance of mid-span transposition information to the joint testing task.
Who it affects: Electricity transmission line testers
Issue owner: Aeropower Pty. Ltd.
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Dec 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-078-SI-02Checklist for joint testing
Number: AO-2008-078-SI-02
Description: AO-2008-078-SI-02:The operator's joint testing procedures were not comprehensive with respect to hazard identification and the use of standard phraseology.
Who it affects: Electricity transmission line testers
Issue owner: Aeropower Pty. Ltd.
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-078-SI-03Supervision
Number: AO-2008-078-SI-03
Description: AO-2008-078-SI-03:There was no direct supervision of the joint testing operations.
Who it affects: The helicopter owner
Issue owner: The helicopter owner
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-078-SI-04Shoulder harness repair
Number: AO-2008-078-SI-04
Description: AO-2008-078-SI-04:The recording lineworker’s shoulder restraint had been repaired using an unapproved stitch pattern and density.
Who it affects: Lineworker’s using shoulder restraints
Issue owner: Harness repair facility
Operation affected: Aviation: General aviation
Date, status, type
Date: 09 Dec 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-089-SI-01Initial recommendation for misaligned stub pipe counter-boring that led to reduced wall thickness
Number: AO-2010-089-SI-01
Description: AO-2010-089-SI-01:On 30 November 2010 the ATSB had, in close consultation with Rolls-Royce and the UK Air Accidents Investigation Branch, established that the occurrence was directly related to the fatigue cracking of an oil feed stub pipe within the No.2 engine’s HP/IP bearing support structure. The ATSB identified the following safety ...
Who it affects: Aircraft equipped with Rolls-Royce plc Trent 900 series engines
Issue owner: Rolls-Royce plc
Operation affected: Aviation: Air transport
Date, status, type
Date: 01 Dec 2010
Status: Adequately addressed
Type: Recommendation
  Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2010-012-SI-01ATC Group Practices
Number: AO-2010-012-SI-01
Description: AO-2010-012-SI-01:Practices used within the ATS Group did not ensure that NOTAMs were effectively reviewed and communicated.
Who it affects: All Airservices Australia air traffic controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 30 Nov 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2010-012-SI-02Out of hours Phone Numbers for Proserpine Airport
Number: AO-2010-012-SI-02
Description: AO-2010-012-SI-02:The Out of Hours telephone numbers for Proserpine Airport, listed in the Jeppesen Airways Manual, were incorrect.
Who it affects: All operators using Proserpine Airport
Issue owner: Other
Operation affected: Aviation: Airports
Date, status, type
Date: 30 Nov 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-075-SI-01Separation assurance at fire locations
Number: AO-2009-075-SI-01
Description: AO-2009-075-SI-01:There were no published communications procedures or phraseology that should before used by pilots during firebombing operations to provide separation assurance at fire locations when there was no air attack supervisor present.
Who it affects: All pilots conducting firebombing operations
Issue owner: NSW Rural Fire Service
Operation affected: Aviation: General aviation
Date, status, type
Date: 29 Nov 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-070-SI-01Regulatory Authorisation to Supervise Agriculture Pilot (Aeroplane) Rating Grade 2 Pilots
Number: AO-2009-070-SI-01
Description: AO-2009-070-SI-01:Confusion within the aerial application industry concerning the correct authorisation for a supervisor of a pilot with an Agriculture Pilot (Aeroplane) Rating Grade 2 (Ag 2) increases the risk of an inappropriately qualified person supervising such a pilot.
Who it affects: Supervisors of Ag 2 pilots
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 26 Nov 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-070-SI-02Guidance for supervision of Agriculture Pilot (Aeroplane) Rating Grade 2 Pilots
Number: AO-2009-070-SI-02
Description: AO-2009-070-SI-02:The lack of guidance material for the supervision of a pilot with an Agriculture Pilot (Aeroplane) Rating Grade 2 increases the risk of inadequate supervision of such a pilot
Who it affects: Supervisors of Ag 2 pilots
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 26 Nov 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-056-SI-01Training and assessment system
Number: AO-2009-056-SI-01
Description: AO-2009-056-SI-01:The training and assessment system was ineffective, in this case, because it placed an individual with deficiencies in scanning and conflict resolution in a control position.
Who it affects: All Airservices Australia Check and Standardisation Specialist controllers
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 24 Nov 2010
Status: Adequately addressed
Issue, description, who it affects
Issue: Aircraft fitted with pressurised oxygen systems
Description: Minor safety issue The safety information provided to passengers did not adequately explain that oxygen will flow to the mask without the reservoir bag inflating. Safety advisory notice The Australian Transport Safety Bureau advises that operators of transport category aircraft fitted with pressurised gaseous oxygen systems should consider the safety implications ...
Who it affects: Operators of aircraft fitted with pressurised oxygen systems
Issue owner:
Operation affected:
Date, status, type
Date: 22 Nov 2010
Original risk: Minor
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: Aircraft fitted with pressurised oxygen systems
Description: The Australian Transport Safety Bureau encourages all organisations performing inspection, testing, maintenance and repair activities on aviation oxygen cylinders, to note the circumstances detailed in this report, with a view to ensuring that all facilities establish and maintain independent external accreditation of their procedures, processes and equipment.
Who it affects: Operators of aircraft fitted with pressurised oxygen systems
Issue owner:
Operation affected:
Date, status, type
Date: 22 Nov 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2008-053-SI-01Cabin procedures in event of PATR failure
Number: AO-2008-053-SI-01
Description: AO-2008-053-SI-01:The operator's cabin emergency procedures did not include specific crew actions to be carried out in the event of a PATR failure.
Who it affects: Operators of passenger transport aircraft fitted with Passenger Address Tape Reproducer (PATR) or similar automatic passenger addressing systems.
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 22 Nov 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-053-SI-02Inadequate passenger safety briefing about oxygen masks
Number: AO-2008-053-SI-02
Description: AO-2008-053-SI-02:The safety information provided to passengers did not adequately explain that oxygen will flow to the masks without the reservoir bag inflating.
Who it affects: Operators of passenger transport aircraft fitted with emergency supplementary breathing oxygen systems.
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 22 Nov 2010
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2008-053-SI-03Cabin crew oxygen flow - uncertainty
Number: AO-2008-053-SI-03
Description: AO-2008-053-SI-03:Some cabin crew-members did not have an appropriate understanding of the oxygen mask flow indication system.
Who it affects: Operators of passenger transport aircraft fitted with emergency supplementary breathing oxygen systems.
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 22 Nov 2010
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2008-053-SI-04Cabin crew understanding of shallow descent angle
Number: AO-2008-053-SI-04
Description: AO-2008-053-SI-04:Some cabin crew-members did not have an appropriate understanding of the aircraft's emergency descent profile, leading to misapprehensions regarding the significance of the situation.
Who it affects: Operators of pressurised passenger transport aircraft.
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 22 Nov 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-053-SI-05Representativeness of cabin crew training facilities
Number: AO-2008-053-SI-05
Description: AO-2008-053-SI-05:Cabin crew training facilities did not appropriately replicate the equipment installed within the aircraft, including the drop-down oxygen mask assemblies.
Who it affects: Operators of passenger transport aircraft fitted with emergency supplementary breathing oxygen systems.
Issue owner: Qantas Airways
Operation affected: Aviation: Air transport
Date, status, type
Date: 22 Nov 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-053-SI-06Independent accreditation of oxygen cylinders facilities
Number: AO-2008-053-SI-06
Description: AO-2008-053-SI-06:While maintaining the appropriate general quality accreditation (ISO 9001) of its engineering facilities, the operator did not maintain independent accreditation of the specific procedures and facilities used for the inspection, maintenance and re-certification of oxygen cylinders.
Who it affects: Maintainers of cylinders and pressure vessels used for aircraft supplementary breathing oxygen systems.
Issue owner: Qantas Airways
Operation affected: Aviation: Maintenance
Date, status, type
Date: 22 Nov 2010
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2010-089-SI-02Intermediate pressure turbine overspeed and burst following failure of drive arm due to internal engine fire
Number: AO-2010-089-SI-02
Description: AO-2010-089-SI-02:Following the separation of the IP turbine disc from the drive arm, the engine behaved in a manner that differed from the engine manufacturer’s modelling and experience with other engines in the Trent family, with the result that the IP turbine disc accelerated to a rotational speed in excess of ...
Who it affects: Ownres and operators of Trent 900 engines
Issue owner: Rolls-Royce plc
Operation affected: Aviation: Air transport
Date, status, type
Date: 04 Nov 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-004-SI-01Aircraft design permitted avionics malfunction via moisture
Number: AO-2009-004-SI-01
Description: AO-2009-004-SI-01:The design and relative positioning of the external air vent and avionics modules permitted the ingress of moisture and particulates that led to corrosion and contamination of electronic avionics components and consequently the generation of multiple erroneous crew alerting system (CAS) messages due to electrical shorting.
Who it affects: Operators of ‘long nose configuration’ AW139 helicopters
Issue owner: Agusta, S.p.A, Construzioni Aeronautiche
Operation affected: Aviation: Other
Date, status, type
Date: 05 Oct 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-004-SI-02Lack of formalised monitoring role
Number: AO-2009-004-SI-02
Description: AO-2009-004-SI-02:The lack of formalised procedures in place requiring the Air Crew Officer (ACO) to monitor key instrument indications probably contributed to the undetected altitude loss.
Who it affects: Helicopter operator
Issue owner: Helicopter operator
Operation affected: Aviation: General aviation
Date, status, type
Date: 05 Oct 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-004-SI-03Lack of deviation alert on ATC system
Number: AO-2009-004-SI-03
Description: AO-2009-004-SI-03:The absence of an altitude deviation alert within the Australian Defence Air Traffic System increases the risk of undetected altitude variation and contributed to the significant loss of altitude.
Who it affects: Operations receiving Air Traffic Services via the Australian Defence Air Traffic System
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 05 Oct 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-004-SI-04Electrical interuption due to water ingress
Number: AO-2009-004-SI-04
Description: AO-2009-004-SI-04:Interruption of electrical power to the multi purpose flight recorder due to water ingress removed of an important source of information used to identify safety issues.
Who it affects: Operators of ‘long nose configuration’ AW139 helicopters
Issue owner: Agusta, S.p.A, Construzioni Aeronautiche
Operation affected: Aviation: General aviation
Date, status, type
Date: 05 Oct 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-021-SI-01Aileron servo valve adjustment
Number: AO-2009-021-SI-01
Description: AO-2009-021-SI-01:The servo valve within the left green aileron servo was incorrectly adjusted during manufacture.
Who it affects: The aircraft manufacturer and aircraft type operators
Issue owner: Component manufacturer
Operation affected: Aviation: Other
Date, status, type
Date: 24 Aug 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-021-SI-02Reporting of incidents
Number: AO-2009-021-SI-02
Description: AO-2009-021-SI-02:The aircraft operator did not comply with the reporting requirements of the Transport Safety Investigation Act 2003.
Who it affects: The aircraft operator
Issue owner: Tiger Airways Australia Pty Limited
Operation affected: Aviation: Air transport
Date, status, type
Date: 24 Aug 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-047-SI-01Nose landing gear residual stress and hydrogen embrittlement
Number: AO-2009-047-SI-01
Description: AO-2009-047-SI-01:Fatigue cracking originated within the aircraft nose landing gear (NLG) right axle as the result of surface damage associated with grinding during manufacture, and was probably assisted in its initiation by hydrogen evolved during plating processes.
Who it affects: Operators of Boeing 737 aircraft
Issue owner: BF Goodrich
Operation affected: Aviation: Other
Date, status, type
Date: 30 Jul 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2009-032-SAN-019
Description: Safety issue The helicopter operator's induction checklist did not include the notation of instructors' ratings and validity periods. Action taken by the ATSB Unless operators actively track the qualifications, endorsements, ratings and recency of their staff, there is the risk that pilots and instructors may operate aircraft with invalid qualifications and ...
Who it affects: Operators and pilots
Issue owner:
Operation affected:
Date, status, type
Date: 28 Jul 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2009-032-SI-01Instructor induction process
Number: AO-2009-032-SI-01
Description: AO-2009-032-SI-01:The helicopter operator's induction checklist did not include the notation of instructors’ ratings and validity periods.
Who it affects: The helicopter operator
Issue owner: Helicopter Flight Centre (Australia)
Operation affected: Aviation: Air transport
Date, status, type
Date: 28 Jul 2010
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2009-032-SI-02Robinson training requirements
Number: AO-2009-032-SI-02
Description: AO-2009-032-SI-02:There were no specific training requirements for Robinson helicopters in Australia, such as those in Federal Aviation Administration Special Federal Aviation Regulation 73-2.
Who it affects: Robinson R22 pilots
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 28 Jul 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2009-053-SAN-038
Description: The Australian Transport Safety Bureau draws the attention of all operators of CFM56-7 and CFM56-5 engines and their variants to the safety issues identified by this investigation. In particular operators should be aware of the potential for premature wear within the compressor variable stator vane bushings and shroud to develop ...
Who it affects: Operators of CFM56-7 and CFM56-5 engines
Issue owner:
Operation affected:
Date, status, type
Date: 27 Jul 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2009-053-SI-01Inadequate maintenance intervals
Number: AO-2009-053-SI-01
Description: AO-2009-053-SI-01:The CFM56-7B engine had sustained bushing and shroud wear sufficient to cause rotor-to-stator contact, after a time in service that was less than the minimum threshold period specified by the manufacturer, for an initial inspection targeted at identifying this problem
Who it affects: The engine manufacturer, operators and maintainers of CFM56-7 and CFM56-5 engines
Issue owner: CFM International (General Electric / SNECMA)
Operation affected: Aviation: Maintenance
Date, status, type
Date: 27 Jul 2010
Status: Partially addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2009-053-SI-02Engine failure susceptibility
Number: AO-2009-053-SI-02
Description: AO-2009-053-SI-02:The CFM56-7B engine design was susceptible to VSV bushing and shroud wear that can lead to internal mechanical damage and potential in-flight performance difficulties.
Who it affects: The engine manufacturer, operators and maintainers of CFM56-7 and CFM56-5 engines
Issue owner: CFM International (General Electric / SNECMA)
Operation affected: Aviation: Air transport
Date, status, type
Date: 27 Jul 2010
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2008-083-SI-01Flight Review guidance
Number: AO-2008-083-SI-01
Description: AO-2008-083-SI-01:The current advice in Civil Aviation Advisory Publication 5.81-1(0) Flight Crew Licensing Flight Reviews in relation to the assessment of navigation skills, represents a missed opportunity to identify a pilot's capacity to make safe and appropriate decisions during cross country flying.
Who it affects: Civil Aviation Safety Authority
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 14 Jul 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2008-083-SI-02CASA Documentation
Number: AO-2008-083-SI-02
Description: AO-2008-083-SI-02:The flight planning requirements at page 88 of the Visual Flight Guide included a transcription error that inadvertently limited the application of the requirements of Civil Aviation Regulation 239.
Who it affects: Civil Aviation Safety Authority
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Other
Date, status, type
Date: 14 Jul 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Number: AO-2008-062-SAN-098
Description: AO-2008-062-SAN-098:There was a lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimised the risk of pilots operating outside the individual pilot's level of competence. [Minor safety issue] Action taken by the ATSB In response to this safety issue, the ATSB issues the following Safety Advisory Notice (SAN). Safety ...
Who it affects: Operator policy, procedures and practices
Issue owner:
Operation affected:
Date, status, type
Date: 07 Jul 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2008-062-SI-02Pilots operating outside level of competence
Number: AO-2008-062-SI-02
Description: AO-2008-062-SI-02:There was a lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimised the risk of pilots operating outside the individual pilot’s level of competence.
Who it affects:
Issue owner: Heliwork WA Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 07 Jul 2010
Status: Partially addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: AO-2008-062-SI-01Robinson-specific training
Number: AO-2008-062-SI-01
Description: AO-2008-062-SI-01:There was no Australian requirement for endorsement and recurrent training conducted on Robinson Helicopter Company R22/R44 helicopters to specifically address the preconditions for, recognition of, or recovery from, low main rotor RPM.
Who it affects:
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 07 Jul 2010
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Number: AO-2007-044-SAN 109
Description: AO-2007-044-SAN 109: This incident highlights the potential for unintended consequences when changes to standard operating procedures are introduced without first conducting an appropriate risk analysis. Therefore, the ATSB advises that all aircraft operators should consider the safety implications of this safety issue and take action where considered appropriate.
Who it affects: All aircraft operators
Issue owner:
Operation affected:
Date, status, type
Date: 24 Feb 2010
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: AO-2007-029-SAN-097
Description: AO-2007-029-SAN-097: Safety advisory notice The Australian Transport Safety Bureau draws the attention of all operators to the contributory and other factors identified by this investigation. Operators are encouraged to review their procedures to ensure an appropriate awareness amongst operating personnel of the implications for aircraft performance of the combination of aircraft weights and speed, and of the ...
Who it affects: All operators
Issue owner:
Operation affected:
Date, status, type
Date: 09 Nov 2009
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: No regulatory requirement for simulator training in Australia
Description: Safety issue There was no regulatory requirement for simulator training in Australia. Action taken by the Civil Aviation Safety Authority A summary of CASA activities to facilitate the use of full flight simulators and/or flight training devices follows: The following inter-related activities are in the process of implementation: A combined workshop activity with Ansett Aviation Training, Capiteq Limited trading as ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 08 Jul 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: AO-2007-066-SR-081
Description: CASA did not seek information to establish whether conditions '...necessary for the safety of other airspace users and persons on the ground or water' were required prior to issuing the Special Certificate of Airworthiness. Action taken by CASA In its response to this safety issue, CASA provided the following response to the ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 25 Jun 2009
Status:
Type: Recommendation
Issue, description, who it affects
Issue: Aviation oxygen cylinders maintenance and inspection
Description: The Australian Transport Safety Bureau encourages all organisations performing inspection, testing, maintenance and repair activities on aviation oxygen cylinders, to note the circumstances detailed in this preliminary report, with a view to ensuring that all relevant procedures, equipment, techniques and personnel qualifications satisfy the applicable regulatory requirements and established engineering ...
Who it affects: Aviation oxygen cylinders maintenance and inspection organisations
Issue owner:
Operation affected:
Date, status, type
Date: 29 Aug 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: Pressurised gaseous oxygen systems
Description: The Australian Transport Safety Bureau encourages other operators of transport category aircraft fitted with pressurised gaseous oxygen systems, to note the circumstances detailed in this preliminary report, with a view to ensuring that all oxygen cylinders, and cylinder installations, are maintained in full accordance with the relevant manufacturer's requirements, statutory ...
Who it affects: Operators of aircraft fitted with pressurised oxygen systems
Issue owner:
Operation affected:
Date, status, type
Date: 29 Aug 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: ARFU transmissions
Description: Some pilots operating at non-towered aerodromes do not fully understand the significance of hearing (or not hearing) the various ARFU transmissions.  
Who it affects: Pilots operating into non-towered aerodromes
Issue owner:
Operation affected:
Date, status, type
Date: 28 Aug 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: International standards and recommended practices guidance on helipads
Description: Following the release of the Preliminary Report into the accident, the helipad operator provided the additional following response on 12 May 2008: With reference to the amended Preliminary Transport Safety Report, sent to us with your letter dated 7 March 2008, we make the following comments: The helicopter pilots involved in the ...
Who it affects: Heli Air Pty Ltd
Issue owner:
Operation affected:
Date, status, type
Date: 14 Mar 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: SAN20080002
Description: SAN20080002:The aircraft manufacturer's maintenance manual contained insufficient instruction or guidance for operators and maintainers of Super King Air 200 aircraft for the lubrication of the landing gear torque tube support bearings.  
Who it affects: Hawker Beechcraft
Issue owner:
Operation affected:
Date, status, type
Date: 08 Feb 2008
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: Windscreen electrostatic filter
Description: An extended time in service in the 'A' windscreen filter location appeared to increase the risk of an electrical arcing event in that filter. Aircraft manufacturer commentIn its consideration of alternate strategies to address the failure of the aircraft's 'A' windscreen electrostatic filter, the aircraft manufacturer determined that there was no ...
Who it affects: BAE SYSTEMS
Issue owner:
Operation affected:
Date, status, type
Date: 06 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Issue: Windscreen electrostatic filter
Description: An extended time in service in the 'A' windscreen filter location appeared to increase the risk of an electrical arcing event in that filter. Aircraft manufacturer commentIn its consideration of alternate strategies to address the failure of the aircraft's 'A' windscreen electrostatic filter, the aircraft manufacturer determined that there was no ...
Who it affects: GKN Aerospace
Issue owner:
Operation affected:
Date, status, type
Date: 06 Feb 2008
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070027
Description: R20070027:Parachutists are not required to utilise helmets while parachuting, thereby increasing their risk of head injury during parachuting and in the event of an aircraft accident. In the event of a head injury during an aircraft accident, their successful exit from an aircraft could be negatively affected.  
Who it affects: Australian Parachute Federation
Issue owner:
Operation affected:
Date, status, type
Date: 30 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070028
Description: R20070028: Safety issue The current configuration of some sports parachuting aircraft may not be conducive to occupant survivability in the event of an aircraft accident. Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Parachute Federation conduct an audit of members' aircraft in order to identify and mitigate potential aircraft equipment-related crash survivability issues.
Who it affects: Australian Parachute Federation
Issue owner:
Operation affected:
Date, status, type
Date: 30 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070029
Description: R20070029: Safety Issue Compliance with the APF Jump Pilot's Handbook & Aircraft Operation Procedures Manual was understood by the APF to not be mandatory for members of the federation. However, it appeared that the manual could be considered an applicable manual in accordance with the schedule. The clarification of the intent of Schedule A has the potential ...
Who it affects: Australian Parachute Federation
Issue owner:
Operation affected:
Date, status, type
Date: 30 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070030
Description: R20070030: Safety issue Currently, Civil Aviation Advisory Publication (CAAP) 42B-1(0) and Airworthiness Bulletin AWB 02-003 Issue 2, are ambiguous regarding required inspection intervals for Private category aircraft airframe items. This may result in the items being operated past the specified aircraft manufacturer's inspection interval. Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review Civil ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 30 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070031
Description: R20070031: Safety issue The practice of harnessing tandem parachutists together during the take-off roll and climb out of the aircraft could negatively impact occupants' survivability in the event of an aircraft-related emergency. Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority advise all self-administered sports parachuting organisations (other than the Australian Parachute Federation) to include ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 30 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070032
Description: R20070032: Safety issue The current configuration of some sports parachuting aircraft may not be conducive to occupant survivability in the event of an aircraft accident. Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority direct that non-Australian Parachute Federation sports parachuting organisations conduct a review of their aircraft in order to identify and mitigate ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 30 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070033
Description: R20070033: Safety issue The current US Federal Aviation Administration approved Supplemental Type Certificate SA2123NM supplemental operational documentation relating to usage of the auxiliary fuel pump in the Cessna U206 is ambiguous regarding the operation of the pump for takeoff. That ambiguity could result in the inappropriate use of the pump and subsequent engine operational issues. ATSB comment As at ...
Who it affects: US Federal Aviation Administration
Issue owner:
Operation affected:
Date, status, type
Date: 30 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070025
Description: R20070025: ATSB comment Note: The same recommendation was issued to Airservices Australia as R20070026. On 21/12/2007, Airservices Australia responded to the recommendation and the ATSB classified it as Closed - Accepted (see /publications/recommendations/2007/R20070026.aspx). Based on that response the ATSB classifies R20070025 as Closed - Accepted.   Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in consultation ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 22 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070026
Description: R20070026: Safety Recommendation The Australian Transport Safety Bureau recommends that Airservices Australia, in consultation with the Civil Aviation Safety Authority, review the requirements for the dissemination of SIGMET information with a view to minimising differences between air traffic control procedures contained in the Aeronautical Information Publication and those contained in ICAO Doc.4444 and ICAO Doc.7030.
Who it affects: Airservices Australia
Issue owner:
Operation affected:
Date, status, type
Date: 22 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070015
Description: R20070015: Safety Recommendation The Australian Transport Safety Bureau recommends that Pratt & Whitney Canada, in conjunction with Transport Canada, incorporate measures to electrically isolate the starter-generator gear-shaft input coupling spline and the engine number-1 main shaft bearing of all Pratt & Whitney Canada PT6A series engines.
Who it affects: Pratt & Whitney Canada
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070016
Description: R20070016: Safety Recommendation The Australian Transport Safety Bureau recommends that Pratt & Whitney Canada, in conjunction with the aircraft and starter-generator manufacturers, incorporate a suitable inspection of the starter generator gear shaft input coupling spline for any evidence of Electrical Discharge Damage (EDD), if the starter generator is replaced in order to rectify a reported engine starting or ...
Who it affects: Pratt & Whitney Canada
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070017
Description: R20070017: Safety Recommendation The Australian Transport Safety Bureau recommends that Pratt & Whitney Canada consider requiring the removal of any PT6A series engine from service where there is evidence of an EDD event.
Who it affects: Pratt & Whitney Canada
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070018
Description: R20070018: Safety Recommendation The Australian Transport Safety Bureau recommends that Cessna Aircraft Company, consider revising the Cessna 208 series aircraft Pilot Information Manual for emergency procedures on chip detector and pilot warnings.
Who it affects: Cessna Aircraft Company
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070019
Description: R20070019: Safety Recommendation The Australian Transport Safety Bureau recommends that Cessna Aircraft Company, revise its procedures in the Cessna 208 aircraft maintenance manual to include the starter-generator manufacturer's recommended brush inspection requirements.
Who it affects: Cessna Aircraft Company
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070020
Description: R20070020: Safety Recommendation The Australian Transport Safety Bureau recommends that Transport Canada, as the state of design for PT6A engines, review the continued airworthiness of PT6A series engines, with regard to its susceptibility to failure of the number-1 bearing, as a result of EDD sustained from a starter-generator malfunction.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070021
Description: R20070021: Safety Recommendation The Australian Transport Safety Bureau recommends that Transport Canada require that Pratt & Whitney Canada incorporate measures to electrically isolate the starter-generator gear-shaft input coupling and the engine number-1 main shaft bearing of all Pratt & Whitney Canada PT6A series engines.
Who it affects: Transport Canada
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070022
Description: R20070022: Safety Recommendation The Australian Transport Safety Bureau recommends that the US Federal Aviation Administration, as the state of design for Lear Seigler (TRW Lucas) and Aircraft Parts Corporation (GE Unison) type starter-generators, examine the circumstances of electrical discharge damage to the number-1 bearing of Pratt & Whitney Canada PT6A series engines and develop an appropriate safety assurance ...
Who it affects: US Federal Aviation Administration
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070023
Description: R20070023: Safety Recommendation The Australian Transport Safety Bureau recommends that the US Federal Aviation Administration consider the benefits of implementing the fitment of accessory gearbox chip detectors on all Cessna 208 aircraft.
Who it affects: Federal Aviation Administration
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070024
Description: R20070024: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority consider the benefits of requiring the fitment of AGB chip detectors on all Australian registered Cessna 208 aircraft used in commercial passenger operations.
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: AO-2007-017-SAN-013
Description: AO-2007-017-SAN-013: Safety Issue The processes used by some turboprop operators for checking the fuel quantity on board prior to flight have not used two methods of sufficient independence. In particular, the practice of using a comparison of a gauge indication after refuelling with the gauge indication prior to refuelling plus the fuel added is not adequate to ...
Who it affects: Turbo prop operators
Issue owner:
Operation affected:
Date, status, type
Date: 14 Sep 2007
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: R20070013
Description: R20070013: Safety Issue The requirements of Civil Aviation Regulation (CAR) 157 and the operator's Approval to conduct Low Flying Instrument did not include any requirement to specifically define the area in which the low flying was carried out. Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety issue.
Who it affects: Civil Aviaiton Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 03 Aug 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070014
Description: R20070014: Safety Issue There was no permanent, widely-available source of contemporary low-flying knowledge and information for access by student and qualified pilots, operators, or by bodies and agencies contemplating or engaged in contracting for the supply of low-level aerial services. Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety issue.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 03 Aug 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070012
Description: R20070012: Safety Issue Both the operator's and the manufacturer's Quick Reference Handbook (QRH) for the DHC8-300 did not contain adequate guidance for the flight crew to resolve the abnormal operation of the aircraft systems. Safety Recommendation The Australian Transport Safety Bureau recommends that Bombardier Aerospace address this safety issue.
Who it affects: Bombardier Aerospace
Issue owner:
Operation affected:
Date, status, type
Date: 08 Jun 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070002
Description: R20070002: Safety Issue CASA did not provide sufficient guidance to its inspectors to enable them to effectively and consistently evaluate several key aspects of operator management systems. These aspects included evaluating organisational structure and staff resources, evaluating the suitability of key personnel, evaluating organisational change, and evaluating risk management processes. Safety Recommendation The Australian Transport Safety Bureau recommends that ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070003
Description: R20070003: Safety Issue CASA did not require operators to conduct structured and/or comprehensive risk assessments, or conduct such assessments itself, when evaluating applications for the initial issue or subsequent variation of an Air Operator's Certificate. Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to address this safety issue.
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070004
Description: R20070004: Safety Issue CASA did not have a systematic process for determining the relative risk levels of airline operators. This issue was discussed in the analysis section of the draft report but was not listed as a safety issue. However, it has now been included as a safety issue following assessment of comments on the draft report. Safety ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070005
Description: R20070005: Safety Issue CASA's process for accepting an instrument approach did not involve a systematic risk assessment of pilot workload and other potential hazards, including activation of a ground proximity warning system. Safety Recommendation The ATSB recommends that the Civil Aviation Safety Authority address this safety issue.
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070006
Description: R20070006:Safety Issue CASA's guidance material provided to operators about the structure and content of an operations manual was not as comprehensive as that provided by ICAO in areas such as multi-crew procedures and stabilised approach criteria. Safety Recommendation The ATSB recommends that the Civil Aviation Safety Authority address this safety issue.
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070007
Description: R20070007: Safety Issue There was no regulatory requirement for instrument approach charts to include coloured contours to depict terrain. This was required by a standard in ICAO Annex 4 in certain situations. Australia had not notified a difference to the standard. Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070008
Description: R20070008: Safety Issue Based on the available evidence, the Lockhart River Runway 12 RNAV (GNSS) approach design resulted in mode 2A ground proximity warning system alerts and warnings when flown on the recommended profile or at the segment minimum safe altitudes. This safety issue was not listed in the draft report but was identified during assessment of ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070009
Description: R20070009: Safety Issue There were several design aspects of the Jeppesen RNAV (GNSS) approach charts that could lead to pilot confusion or reduction in situational awareness. These included limited reference regarding the 'distance to run' to the missed approach point, mismatches in the vertical alignment of the plan-view and profile-view on charts such as that for the ...
Who it affects: Jeppesen Sanderson
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070010
Description: R20070010: Safety Issue Jeppesen instrument approach charts depicted coloured contours on the plan-view of approach charts based on the maximum height of terrain relative to the airfield only, rather than also considering terrain that increases the final approach or missed approach procedure gradient to be steeper than the optimum. Jeppesen instrument approach charts did not depict the ...
Who it affects: Jeppesen Sanderson
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20070011
Description: R20070011: Safety Issue Airservices Australia's instrument approach charts did not depict the terrain contours on the plan-view. They also did not depict the terrain profile on the profile-view, although the segment minimum safe altitudes were depicted. Safety Recommendation The Australian Transport Safety Bureau recommends that Airservices Australia address this safety issue.
Who it affects: Airservices Australia
Issue owner:
Operation affected:
Date, status, type
Date: 04 Apr 2007
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060019
Description: R20060019: Safety issue: RNAV (GNSS) approach pilot workload and situational awareness Pilot workload was perceived as being higher, and reported losses of situational awareness were reported as more common, for the area navigation global navigation satellite system (RNAV (GNSS)) approach than all other approaches except the non-directional beacon (NDB) approach, which involved similar workload and situational awareness levels. This ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 16 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060020
Description: R20060020: Safety issue: RNAV (GNSS) approach chart design and interpretability The most common concern identified by respondents about the design of RNAV (GNSS) approaches was that the charts did not use references for distance to the missed approach point throughout the approach on the global positioning system (GPS) or flight management system (FMS) displays, and distance references ...
Who it affects: Airservices Australia
Issue owner:
Operation affected:
Date, status, type
Date: 16 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060021
Description: R20060021: Safety issue: Sub-optimal RNAV (GNSS) approach design The 21.5% of Australian area navigation global navigation satellite system (RNAV (GNSS)) approaches deviates from the optimum design parameters (short and irregular segments less than 5 NM and/or multiple steps within segments, and/or multiple minimum segment altitude steps) particularly approaches in the vicinity of high terrain. This was identified as ...
Who it affects: Airservices Australia
Issue owner:
Operation affected:
Date, status, type
Date: 16 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060022
Description: R20060022: Safety issue: RNAV (GNSS) approach chart waypoint naming convention The naming convention of using five capital letters for waypoint names, with only the final letter differing to identify each segment of the approach, was reported to cause clutter on the charts and GPS and FMS displays, and also increase the chance of a pilot misinterpreting a ...
Who it affects: Airservices Australia
Issue owner:
Operation affected:
Date, status, type
Date: 16 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060023
Description: R20060023: Safety issue: RNAV (GNSS) approach late notice of air traffic control clearance Late notice of clearance by air traffic control to conduct an RNAV (GNSS) approach was identified as the most common difficult external condition affecting an RNAV (GNSS) approach, particularly for high capacity airline pilots. An examination of opportunities to improve training and/or procedures for ...
Who it affects: Airservices Australia
Issue owner:
Operation affected:
Date, status, type
Date: 16 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060024
Description: R20060024: Safety Issue: RNAV (GNSS) approach late notice of air traffic control clearance. Late notice of clearance by air traffic control to conduct an RNAV (GNSS) approach was identified as the most common difficult external condition affecting an RNAV (GNSS) approach, particularly for high capacity airline pilots. An examination of opportunities to improve training and/or procedures for ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 16 Dec 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060018
Description: R20060018: Safety Recommendation The Australian Transport Safety Bureau recommends that Airservices Australia review guidance material and training for aerodrome controllers relating to the provision of relevant traffic information, to enhance pilot situational awareness.
Who it affects: Airservices Australia
Issue owner:
Operation affected:
Date, status, type
Date: 03 Oct 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060017
Description: R20060017: Safety Recommendation The Australian Transport Safety Bureau recommends that the United States Federal Aviation Administration consider revising Title 14 Code of the Federal Regulations, Part 23.1155, to require a positive means to prevent operation of the propeller in the beta mode while in flight (regardless of pilot action), unless the aircraft is certified for such use.
Who it affects: United States Federal Aviation Administration
Issue owner:
Operation affected:
Date, status, type
Date: 07 Jul 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: SN20060016
Description: SN20060016: Safety Advisory Notice SAN20060016 The Australian Transport Safety Bureau advises owners, operators, maintainers and manufacturers of autogyro rotorcraft (gyrocopters) of the potential for premature failure of the rotor hub bar or related components as a result of fatigue cracking developing from bolted connections within the hub bar assembly.
Who it affects: Owners, operators, maintainers and manufacturers of autogyro rotorcraft - gyrocopters
Issue owner:
Operation affected:
Date, status, type
Date: 29 Jun 2006
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: 20060014
Description: 20060014: The Australian Transport Safety Bureau suggests that the Department of Defence distributes this report widely among controllers so that supervisors are aware that intervention in separation and sequencing at the tactical level has the potential to adversely affect the situational awareness of the controllers under their supervision. Further, they must be prepared to take control of ...
Who it affects: Department of Defence
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2006
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: 20060015
Description: 20060015: Safety Advisory Notice The Australian Transport Safety Bureau suggests that the Department of Defence ensures that controllers are aware of the importance of the separation assurance provisions of MATS 4.1.1.4.
Who it affects: Department of Defence
Issue owner:
Operation affected:
Date, status, type
Date: 26 Jun 2006
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: R20060010
Description: R20060010: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority publish educational material, to promote greater awareness of the flat light phenomenon for pilots operating in susceptible areas.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 11 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060013
Description: R20060013: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review its surveillance methods, which may include cooperation with Airservices Australia, for the detection of patterns of unsafe practices and noncompliance with regulatory requirements.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 11 May 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: IR19990190
Description: IR19990190: The Australian Transport Safety Bureau (formerly BASI) recommends that the Australian Defence Force review Inflight Emergency Response (IFER) training for air traffic services staff responsible for the provision of services to civil aircraft.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Apr 2006
Status:
Type: Interim Recommendation
Issue, description, who it affects
Number: R20060008
Description: R20060008:Safety Issue The Civil Aviation Safety Authority should also consider the requirements for Terrain Awareness Warning Systems for Australian registered turbine-powered helicopters against the background of the US NTSB recommendation for the fitment to turbine-powered helicopters certificated to carry six or more passenger seats. Safety Recommendation The Australian Transport Safety Bureau recommends that ...
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 09 Mar 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050010
Description: R20050010: Safety Recommendation The Australian Transport Safety Bureau recommends that Airservices Australia review MATS 4.5.2.2 to ensure that separation between aircraft, established by the use of visual observation of aircraft position and projected flight paths, is more clearly defined and consistently applied.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050011
Description: R20050011: Safety Recommendation The Australian Transport Safety Bureau recommends that Airservices Australia ensure that controllers are aware of the importance of the separation assurance provisions of MATS 4.1.1.4, particularly in the application of procedural separation.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060005
Description: R20060005: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review the maintenance requirements for cockpit voice recording systems and flight data recording systems against international standards such as EUROCAE ED-112 and ICAO Annex 6 with the aim of improving their reliability and increasing the availability of data to investigators.
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 10 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060006
Description: R20060006: Safety Recommendation The Australian Transport Safety Bureau recommends that the Department of Transport and Regional Services, with the assistance of the Civil Aviation Safety Authority, pursues further the development of proposals to amend the provisions of Part IIIB of the Civil Aviation Act 1988. While recognising the need to have protections to prevent inappropriate disclosure and ...
Who it affects: Department of Transport and Regional Services, with the assistance of the Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 10 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060004
Description: R20060004: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority (CASA), review the requirements for the carriage of on-board recording devices in Australian registered aircraft as a consequence of technological developments.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 02 Feb 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060002
Description: R20060002: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review and clarify the legal requirements concerning the qualifications for two-crew (pilot) operation during the conduct of instrument approaches in air transport operations. The review should assess the safety benefit arising from ensuring that when an instrument approach is conducted in an ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 24 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20060003
Description: R20060003: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review the adequacy of current legislation and regulations: to assess the safety benefit that could be achieved from the fitment of a serviceable autopilot to all aircraft currently on the Australian civil aircraft register, engaged on scheduled air transport operations with a view to ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 24 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050058
Description: RR20050058: The Australian Transport Safety Bureau recommends that the ARTC review the maintenance standards for track inspections and observations, including reporting and remedial actions, to ensure that physical track is consistent with track standards in NSW.
Who it affects: Australian Rail Track Corporation Ltd
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050059
Description: RR20050059: The Australian Transport Safety Bureau recommends that the ARTC identify high risk areas of wide gauge and implement an effective monitoring and remedial regime.
Who it affects: Australian Rail Track Corporation Ltd
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050060
Description: RR20050060: The Australian Transport Safety Bureau recommends that Pacific National review the implications of asymmetric wheel tracking and wear on rail vehicle safety.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050061
Description: RR20050061: The Australian Transport Safety Bureau recommends that Pacific National review the effect of lateral wheel load forces in relation to asymmetric wheel tracking and wear on rail vehicle safety.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050062
Description: RR20050062: The Australian Transport Safety Bureau recommends that Pacific National reinforce the requirements of the ARTC network rules and procedures regarding the protection of trains.
Who it affects: Pacific National
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: RR20050063
Description: RR20050063: The Australian Transport Safety Bureau recommends that ITSRR, during routine audits, ensure that ARTC track in NSW complies with accredited ARTC track standards.
Who it affects: Independent Transport Safety And Reliability Regulator (New South Wales)
Issue owner:
Operation affected:
Date, status, type
Date: 23 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040078
Description: R20040078: Safety Recommendation As a result of this investigation the Australian Transport Safety Bureau recommends that M7 Aerospace Pty Ltd review and amend its Fairchild SA-227 series maintenance manual to ensure that notes on operational tests, with regard to stabiliser movement versus trim switch position referred to in Section 27-40-10 for removal of the pitch trim switch, ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 03 Jan 2006
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050013
Description: R20050013: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority alert operators and review the continuing airworthiness of all Australian registered Fairchild Industries SA227 model aircraft, or other aircraft model types using fuel immersed capacitance-type fuel sensors (probes), with specific regard to possible high impedance wire chafing within the fuel tank.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 23 Dec 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050014
Description: R20050014:Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority alert Australian operators of Kawasaki BK117 B-2 helicopter to the discrepancy with respect to the procedure for adjusting the collective pitch settings in the maintenance manual.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 22 Dec 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050005
Description: R20050005: Safety Recommendation The Australian Transport Safety Bureau recommends that BF Goodrich Aerospace formalise instructions to operators and maintenance organisations for the periodic inspection, based upon BFG SL 1714, of all Boeing 727 main landing gear wheels that have undergone a hub bushing repair.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 09 Dec 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050006
Description: R20050006: Safety Recommendation The Australian Transport Safety Bureau recommends that Asian Express Airlines Pty Ltd implement a periodic inspection routine, based on BFG SL 1714, of all main landing gear wheels that have undergone a hub bushing repair.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 09 Dec 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050008
Description: R20050008: Safety Recommendation The Australian Transport Safety Bureau recommends that National Jet Express Pty Ltd implement a periodic inspection routine, based on BFG SL 1714, of all main landing gear wheels that have undergone a hub bushing repair.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 09 Dec 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050009
Description: R20050009:Safety Recommendation The Australian Transport Safety Bureau recommends that Aviation Australia Pty Ltd implement a periodic inspection routine, based on BFG SL 1714, of all main landing gear wheels that have undergone a hub bushing repair.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 09 Oct 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050003
Description: R20050003: Safety Recommendation The Australian Transport Safety Bureau recommends that Qantas Airways Ltd, review the adequacy of their procedures for the deployment of over-wing slides during known brake fire situations. This review should take into consideration the visual cues used and potential risk to passengers of evacuating within close proximity of a fire zone
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 17 Mar 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050004
Description: R20050004: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Bureau, review the adequacy of operator procedures for the deployment of over-wing slides during known brake fire situations. This review should take into consideration the visual cues used and potential risk to passengers of evacuating within close proximity of a fire zone
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 17 Mar 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040084
Description: R20040084: Safety Recommendation The Australian Transport Safety Bureau recommends that Pratt & Whitney plc review the processes used by its Singapore based overhaul joint venture to accomplish VSV ring pin flaring and compliance with service bulletin PW4ENG 72-432, to ensure the processes are appropriate and in accordance with the service bulletin.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 15 Mar 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040086
Description: R20040086 : Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Authority of Singapore liaises with Pratt & Witney's Singapore based overhaul joint venture to review the process for accomplishing the ring pin flaring and compliance with the service bulletin PW4ENG72432 to ensure the processes are appropriate and in accordance with the service bulletin.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 15 Mar 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040087
Description: R20040087: Safety Recommendation The Australian Transport Safety Bureau recommends that Pratt & Whitney plc review Pratt & Whitney PW4000 engine maintenance procedures for ensuring the integrity of high pressure compressor variable stator vane synchronizing ring pins, to ensure that they adequately address and manage the potential for loss of vane arm pin retention.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 15 Mar 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040088
Description: R20040088: Safety Recommendation The Australian Transport Safety Bureau recommends that the US Federal Aviation Administration review Pratt & Whitney PW4000 engine maintenance procedures for ensuring the integrity of high pressure compressor variable stator vane synchronizing ring pins, to ensure that they adequately address and manage the potential for loss of vane arm pin retention.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 15 Mar 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20050002
Description: R20050002: Safety Issue During consultation during the directly involved parties process regarding issues related to this recommendation, CASA indicated that it would act to: * Review the requirements for helicopter EMS operations to include consideration for two pilots, or a stability augmentation and/or autopilot system * Review the special operational and environmental circumstances of helicopter EMS services, ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 14 Mar 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040090
Description: R20040090: Safety Recommendation The Australian Transport Safety Bureau recommends that the Department of Defence (airport infrastructure owner) and Darwin International Airport Pty Ltd (civilian facilities operator) consider installation of centreline lighting and touchdown zone lighting, consistent with CASA recommended practices on runways wider than 50 m.
Who it affects: Department of Defence
Issue owner:
Operation affected:
Date, status, type
Date: 04 Mar 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040094
Description: R20040094: Safety Recommendation The Australian Transport Safety Bureau recommends that as a priority the International Civil Aviation Organisation develop an international standard for the marking of aircraft equipped with rocket-assisted recovery parachute systems to ensure that they fully alert persons to the hazards and the danger areas on the aircraft.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 21 Jan 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040095
Description: R20040095: Safety Recommendation The Australian Transport Safety Bureau recommends that as a priority the Federal Aviation Administration liaise with the European Aviation Safety Agency and the International Civil Aviation Organisation to develop an international standard for the marking on all aircraft with rocket-assisted recovery parachute systems to ensure that they fully alert persons to the hazards and the ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 21 Jan 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040096
Description: R20040096: Safety Recommendation The Australian Transport Safety Bureau recommends that as a priority the European Aviation Safety Agency liaise with the Federal Aviation Administration and the International Civil Aviation Organisation to develop an international standard for the marking on all aircraft with rocket-assisted recovery parachute systems to ensure that they fully alert persons to the hazards and the ...
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 21 Jan 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040097
Description: R20040097: Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Civil Aviation Safety Authority publish guidance alerting all personnel who would normally attend an accident site to the dangers associated with aircraft equipped with rocket-assisted recovery parachute systems.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 21 Jan 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040091
Description: R20040091: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review the medical certification standards to consider the potential increased significance of diastolic blood pressure to the risk of a cardiac event in applicants for an aviation medical certificate.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 13 Jan 2005
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040093
Description: R20040093: Safety Recommendation In light of the recent industry experience, the Australian Transport Safety Bureau recommends that Australian operators of Boeing 737-800 series aircraft review the practice of fitting retread tyres of R4 (fourth retread) or above, until their serviceability limitations can be identified.
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 23 Dec 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040071
Description: R20040071: not issued
Who it affects:
Issue owner:
Operation affected:
Date, status, type
Date: 06 Dec 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: SAN20040076
Description: SAN20040076: Safety Advisory Notice The Australian Transport Safety Bureau advises constructors of Canadian Safari and other lightweight helicopters to review the installation of an engine speed governor.
Who it affects: Lightweight helicopters manufactuers
Issue owner:
Operation affected:
Date, status, type
Date: 03 Nov 2004
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: SAN20040077
Description: SAN20040077: Safety Advisory Notice The Australian Transport Safety Bureau advises constructors of Canadian Safari and other lightweight helicopters to review the safety benefits of providing discernibly different aural warning tones to differentiate between main rotor RPM overspeed and underspeed conditions.
Who it affects: Light helicopters manufacturers
Issue owner:
Operation affected:
Date, status, type
Date: 03 Nov 2004
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: R20040074
Description: R20040074: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority advise operators of Beechcraft King Air and Raytheon King Air aircraft of the potential safety deficiency of the cabin door warning system becoming prematurely earthed, resulting in a sense switch or switches no longer providing an electrical signal for its or their ...
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Date, status, type
Date: 25 Oct 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040075
Description: R20040075: Safety Recommendation The Australian Transport Safety Bureau recommends that the US Federal Aviation Administration advise operators of Beechcraft King Air and Raytheon King Air aircraft of the potential safety deficiency of the cabin door warning system becoming prematurely earthed, resulting in a sense switch or switches no longer providing an electrical signal for its or their ...
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Date, status, type
Date: 25 Oct 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040072
Description: R20040072: Safety Recommendation The Australian Transport Safety Bureau recommends that Bell Helicopters consider incorporating a change to the Bell 206B Flight Manual to alert owners of helicopters of this type to the possibility of uncovering the fuel pump inlets during out-of-trim flight at a low fuel level.
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Date, status, type
Date: 12 Jul 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040073
Description: R20040073: Safety Recommendation The Australian Transport Safety Bureau recommends that Bell Helicopters consider the incorporation of a specific note in all maintenance manuals highlighting to maintenance personnel the possibility of incorrect orientation of the lower tank unit float arm.
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Date, status, type
Date: 12 Jul 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040064
Description: R20040064: Safety Recommendation The ATSB recommends that CASA conduct a national review of the level of operator compliance with the requirements of mandatory turbine engine condition monitoring programs, particularly for passenger carrying operations.
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Date, status, type
Date: 25 Jun 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040065
Description: R20040065: Safety Recommendation The ATSB recommends that CASA review its surveillance processes to ensure that, during future surveillance activities, priority is given to confirming operator compliance with the requirements of mandatory turbine engine condition monitoring programs, particularly for passenger carrying operations.
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Date, status, type
Date: 25 Jun 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040066
Description: R20040066: Safety Recommendation The ATSB recommends that CASA review its airworthiness surveillance processes and Certificate of Approval assessment processes to ensure that it provides adequate guidelines to assist CASA inspectors to identify priority areas for consideration during surveillance and approval activities, such as programs for compliance with the requirements of Airworthiness Directives.
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Date, status, type
Date: 25 Jun 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040067
Description: R20040067: Safety Recommendation The ATSB recommends that CASA review its airworthiness surveillance processes and Certificate of Approval assessment processes to ensure that it provides specific guidelines to assist CASA inspectors to assess whether a maintenance organisation has adequate personnel resources to conduct its required activities.
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Issue owner:
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Date, status, type
Date: 25 Jun 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040068
Description: R20040068: Safety Recommendation The ATSB recommends that CASA consider providing formal advisory material for operators and pilots, based on relevant research and publications, about managing engine failures and other emergencies during takeoff in multi-engine aircraft below 5,700 kg MTOW. This material should include the factors to be considered by operators when developing procedures for responding to such ...
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Date, status, type
Date: 25 Jun 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040069
Description: R20040069: Safety Recommendation The ATSB recommends that CASA consider and evaluate options to improve the suitability of industry practices for training pilots to make appropriate decisions when responding to engine failures and other emergencies during critical phases of flight in multi-engine aircraft below 5,700 kg MTOW. This review should include an assessment of the suitability of utilising ...
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Date, status, type
Date: 25 Jun 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040070
Description: R20040070: Safety Recommendation The ATSB recommends that the Toowoomba City Council liaise with CASA to evaluate an engineering solution to enhance aircraft deceleration in the runway end safety area of runway 11/29 at Toowoomba aerodrome.
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Date, status, type
Date: 25 Jun 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040062
Description: R20040062: Safety Recommendation The Australian Transport Safety Bureau recommends that Airservices Australia review the effectiveness of its check and training program in the area of procedural control services.
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Date, status, type
Date: 07 Jun 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040063
Description: R20040063: Safety Recommendation The Australian Transport Safety Bureau recommends that Airservices Australia review the MATS amendment decision that removed the mandatory requirement to provide traffic information to aerodrome traffic.
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Date, status, type
Date: 07 Jun 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040052
Description: R20040052: Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Civil Aviation Safety Authority assess the safety benefits of requiring a standby attitude indicator, with an independent power source, in all helicopters operating flights under the NVFR in the Charter and Aerial Work category, excluding dual pilot training.
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Date, status, type
Date: 12 May 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040053
Description: R20040053: Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Civil Aviation Safety Authority assess the safety benefits of requiring an autopilot or stability augmentation system in all single pilot helicopter operating flight under the NVFR, in the Charter and Aerial Work category, excluding dual pilot training.
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 12 May 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040058
Description: R20040058: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority assess the safety benefit of mandating Cessna Alert Bulletin CAB01-15 with regard to the Emergency Power Lever on all Approved Single Engine Turbine Powered Aeroplane Australian registered C208 aircraft.
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Date, status, type
Date: 12 May 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040056
Description: R20040056: Safety Recommendation The Australian Transport Safety Bureau recommends that Airservices Australia estimate the overall midair collision risk at major general aviation airports (Archerfield, Bankstown, Jandakot, Moorabbin and Parafield) and compare these estimated risk levels with relevant acceptable risk criteria.
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Date, status, type
Date: 04 May 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040057
Description: R20040057: Safety Recommendation The Australian Transport Safety Bureau recommends that CASA develop formal advisory material for pilots, based on relevant research and publications, about collision risk management strategies. This formal guidance material should include, but not necessarily be limited to, information on visual scanning techniques, situations where visual scanning is most important, other techniques to increase the likelihood ...
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Date, status, type
Date: 04 May 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040054
Description: R20040054:Safety Recommendation The ATSB recommends that the Civil Aviation Safety Authority review MAF Aviation Services Engineering Order 0071-001 E1 and the cadmium plating and baking process controls employed by the plating subcontractor to determine if the process and process controls prevent the occurrence of hydrogen-induced delayed cracking in high-strength steel engine ...
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Date, status, type
Date: 29 Mar 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040039
Description: R20040039: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority, in conjunction with the Department of Transport and Regional Services, establish the safety benefits of the introduction of a drug and alcohol testing program to the Australian aviation industry for safety-sensitive personnel. Where possible, this program should harmonise with existing and evolving national ...
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Date, status, type
Date: 18 Mar 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040040
Description: R20040040: Safety Recommendation The Australian Transport Safety Bureau recommends that the Department of Transport and Regional Services, in conjunction with the Civil Aviation Safety Authority, establish the safety benefits of the introduction of a drug and alcohol testing program to the Australian aviation industry for safety-sensitive personnel. Where possible, this program should harmonise with existing and evolving national ...
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Date, status, type
Date: 18 Mar 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040041
Description: R20040041: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority revise the content of the pilot Day VFR Syllabi to include contemporary aviation medical knowledge regarding the effects of alcohol and illicit drugs use on human performance, and disseminate that information to qualified pilots via a comprehensive education program.
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Date, status, type
Date: 18 Mar 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040042
Description: R20040042: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review their Safety Trend Indicator process, including with a view to developing a methodology to assist in objectively assessing potential at-risk organisations. That should include formal 'triggers' that enable the consistent prediction of the requirement for additional surveillance until CASR Part 119 takes ...
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Date, status, type
Date: 18 Mar 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: SAN20040043
Description: SAN20040043: Safety Advisory Notice The ATSB suggests that CASA, through its industry publications, inform operators and pilots of Cherokee Six aircraft that a fuel selector control visual indication might not ensure selection of the intended fuel tank. In that case, actual fuel tank selection may be incorrect or partial, and result in the possibility for inconsistent engine ...
Who it affects: CASA and operators and pilots of Cherokee Six
Issue owner:
Operation affected:
Date, status, type
Date: 18 Mar 2004
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: SAN20040044
Description: SAN20040044: Safety Advisory Notice The ATSB suggests that CASA, through its industry publications, should inform operators that a pilot's induction program should reflect the risks inherent in the proposed operation, and take account of the pilot's competencies, recency and proficiency relative to those risks.
Who it affects: Civil Aviation Safety Authority
Issue owner:
Operation affected:
Date, status, type
Date: 18 Mar 2004
Status:
Type: Safety Advisory Notice
Issue, description, who it affects
Number: R20030230
Description: R20030230: Safety Recommendation The Australian Transport Safety Bureau recommends that the Australian Civil Aviation Safety Authority issue advisory information to all pilots, restating the information contained in United States of America Federal Aviation Administration Advisory Circular AC 20-113 pertaining to aircraft engine induction system icing.
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Date, status, type
Date: 01 Mar 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030007
Description: R20030007: Safety Recommendation The Australian Transport Safety Bureau recommends that all Australian Saab 340 operators review the design of the Saab 340 abnormal and emergency checklists, with reference to current human factors research findings on the design and use of aircraft checklists.
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Date, status, type
Date: 26 Feb 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030008
Description: R20030008: Safety Recommendation The Australian Transport Safety Bureau recommends that Saab Aircraft AB redesign the Saab 340 abnormal and emergency checklists to improve usability, with reference to current human factors research findings on the use and design of aircraft checklists.
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Date, status, type
Date: 26 Feb 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030009
Description: R20030009: Safety Recommendation The Australian Transport Safety Bureau recommends that the Aviation safety Authority of Sweden (Luftfartsverket) review the design of the Saab 340 abnormal and emergency checklists with reference to current human factors research findings on the design and use of aircraft checklists.
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Date, status, type
Date: 26 Feb 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030010
Description: R20030010: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review their existing approvals of the Saab 340 abnormal and emergency checklists, with reference to current human factors research findings on the design and use of aircraft checklists.
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Date, status, type
Date: 26 Feb 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030013
Description: R20030013: Safety Recommendation The Australian Transport Safety Bureau recommends that all Australian Saab 340 operators assess the safety benefit of implementing Saab Aircraft AB Service Bulletin 340-24-026 incorporating generator control unit modification number 2533.
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Date, status, type
Date: 26 Feb 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030014
Description: R20030014: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority assess the safety benefit of mandating Saab Aircraft AB Service Bulletin 340-24-026 incorporating generator control unit modification number 2533.
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Issue owner:
Operation affected:
Date, status, type
Date: 26 Feb 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030015
Description: R20030015: Safety Recommendation The Australian Transport Safety Bureau recommends that the Aviation safety Authority of Sweden (Luftfartsverket) assess the safety benefit of mandating Saab Aircraft AB Service Bulletin 340-24-026 incorporating generator control unit modification number 2533.
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Issue owner:
Operation affected:
Date, status, type
Date: 26 Feb 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030016
Description: R20030016: Safety Recommendation The Australian Transport Safety Bureau recommends that the Federal Aviation Administration assess the safety benefit of mandating Saab Aircraft AB Service Bulletin 340-24-026 incorporating generator control unit modification number 2533.
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Issue owner:
Operation affected:
Date, status, type
Date: 26 Feb 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030018
Description: R20030018: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review their existing approvals of Saab 340 systems of maintenance to ensure continued consistency with maintenance review board report requirements for the Saab 340.
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Date, status, type
Date: 26 Feb 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030180
Description: R20030180: Safety Recommendation The Australian Transport Safety Bureau recommends that Hazelton Airlines note the circumstances of the above incident where Saab 340 aircraft can stall without warning in icing conditions and alert their flight crew accordingly.
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Date, status, type
Date: 28 Jan 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030179
Description: R20030179: Safety Recommendation The Australian Transport Safety Bureau recommends that Regional Express note the circumstances of the above incident where Saab 340 aircraft can stall without warning in icing conditions and alert their flight crew accordingly.
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Date, status, type
Date: 20 Jan 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030181
Description: R20030181: Safety Recommendation The Australian Transport Safety Bureau recommends that Macair note the circumstances of the above incident where Saab 340 aircraft can stall without warning in icing conditions and alert their flight crew accordingly.
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Date, status, type
Date: 20 Jan 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030182
Description: R20030182: Safety Recommendation The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority examine the circumstances surrounding this incident where Saab 340 aircraft can stall without warning in icing conditions and take appropriate action to ensure the safety of the Saab 340 fleet operating within Australia.
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Date, status, type
Date: 20 Jan 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20030183
Description: R20030183: Safety Recommendation The Australian Transport Safety Bureau recommends that, as a matter of priority, Saab Aircraft AB modify the stall warning system of the worldwide fleet of Saab 340 aircraft to give sufficient warning of an impending stall to crews during flight in icing conditions.
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Date, status, type
Date: 20 Jan 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040013
Description: R20040013: Safety Recommendation The ATSB recommends that the Civil Aviation Safety Authority, in consultation with Airservices Australia and the NAS Implementation Group, review NAS procedures and communications requirements for operations in Class E airspace, with particular emphasis on air transport operations during climb and descent in non-radar airspace, with a view to enhancing situational awareness of pilots operating ...
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Date, status, type
Date: 15 Jan 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040014
Description: R20040014: Safety Recommendation The ATSB recommends that Airservices Australia, in consultation with the Civil Aviation Safety Authority and the NAS Implementation Group, review NAS procedures and communications requirements for operations in Class E airspace, with particular emphasis on air transport operations during climb and descent in non-radar airspace, with a view to enhancing situational awareness of pilots operating ...
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Date, status, type
Date: 15 Jan 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040015
Description: R20040015: Safety Recommendation The CAA should take into account the limitations of see-and-avoid when planning and managing airspace and should ensure that unalerted see-and-avoid is never the sole means of separation for aircraft providing scheduled services. Note: The Recommendation was issued to the [then] Civil Aviation Authority (CAA) in 1991 and in 2001 the ATSB and CASA ...
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Date, status, type
Date: 13 Jan 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040016
Description: R20040016: Safety Recommendation In light of the serious limitations of the see-and-avoid concept, the CAA should continue to closely monitor the implementation of TCAS in the US and should consider the system for Australia. Note: The Recommendation was issued to the [then] Civil Aviation Authority (CAA) in 1991.
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Date, status, type
Date: 13 Jan 2004
Status:
Type: Recommendation
Issue, description, who it affects
Number: R20040017
Description: R20040017: Safety Recommendation The CAA should ensure that pilots are trained in effective traffic scans. Note: The Recommendation was issued to the [then] Civil Aviation Authority (CAA) in 1991.