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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: MO-2016-007-SI-01Steering gear planned maintenance instructions
Number: MO-2016-007-SI-01
Description: MO-2016-007-SI-01:Bow Singapore’s planned maintenance system for the steering gear did not include or contain any schedules for detailed inspections or parts replacement.
Who it affects: All workers on ships managed by Odfjell Management
Issue owner: Odfjell Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Oct 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-029-SI-04Track maintenance personnel training and development
Number: RO-2015-029-SI-04
Description: RO-2015-029-SI-04:There was an identified gap in the knowledge of track maintenance personnel that was probably the result of deficiencies in training and development. In addition, network standards for the assessment of track lateral stability, including creep management, provided limited information and tools for maintenance personnel.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 12 Jul 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-029-SI-03Other track inspections
Number: RO-2015-029-SI-03
Description: RO-2015-029-SI-03:There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 12 Jul 2017
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-029-SI-02Correcting rail creep for fixed points
Number: RO-2015-029-SI-02
Description: RO-2015-029-SI-02:Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 12 Jul 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-029-SI-01Rail creep
Number: RO-2015-029-SI-01
Description: RO-2015-029-SI-01:Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 12 Jul 2017
Status: Adequately addressed
Type: Proactive Action
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: RO-2016-007-SI-01 Rail fractures
Number: RO-2016-007-SI-01
Description: RO-2016-007-SI-01 :The inspection regime to identify rail fractures was ineffective for the condition of this track.
Who it affects: All operators of rail freight
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Freight
Date, status, type
Date: 30 May 2017
Status:
Type: Proactive Action
  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: RO-2015-022-SI-04 Correcting rail creep for fixed points
Number: RO-2015-022-SI-04
Description: RO-2015-022-SI-04 :Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-03 Timeframe for addressing identified rail creep
Number: RO-2015-022-SI-03
Description: RO-2015-022-SI-03 :The procedures for measuring, assessing, and remediating rail creep in spring did not ensure creep defects were addressed in a timely manner and prior to the onset of hot weather. A creep defect identified by the spring measurements was not corrected before the derailment.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-02 Other track inspections
Number: RO-2015-022-SI-02
Description: RO-2015-022-SI-02 :There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-022-SI-01 Rail creep
Number: RO-2015-022-SI-01
Description: RO-2015-022-SI-01 :Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.
Who it affects: Managers of rail networks
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2016-001-SI-03Mooring at Station Pier
Number: MO-2016-001-SI-03
Description: MO-2016-001-SI-03:While TT-Line Company’s standard mooring line pattern for ships at Station Pier had been successfully used for many years, the breakaway indicated the risk could have been further reduced to better prepare for such unusual circumstances.
Who it affects: All ship masters and deck officers
Issue owner: TT-Line Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 May 2017
Status: Partially addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2016-001-SI-02Melbourne vessel traffic service procedures
Number: MO-2016-001-SI-02
Description: MO-2016-001-SI-02:The Port of Melbourne vessel traffic service (VTS) procedures for adverse weather were not comprehensive and, hence, its response on 13 January was only partially effective. One important consequence was that VTS’s advance warning of storm force winds did not reach all relevant parties, including Spirit of Tasmania II’s master.
Who it affects: Port of Melbourne vessel traffic service and all users of the port
Issue owner: Victorian Ports Corporation (Melbourne)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 11 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2016-001-SI-01TT-Line Company procedures
Number: MO-2016-001-SI-01
Description: MO-2016-001-SI-01:The adverse weather procedures for TT-Line Company ships when alongside did not take into account all the necessary factors to provide effective defences against significant, short-term weather events such as thunderstorms and squalls.
Who it affects: All ship masters and deck officers
Issue owner: TT-Line Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 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: RO-2015-009-SI-02 Network rule governing Distant signals
Number: RO-2015-009-SI-02
Description: RO-2015-009-SI-02 :The rule describing the required driver response to a Distant signal at Caution in a two-position signalling system did not fully reflect the signalling system design principles. 
Who it affects: Drivers operating on rail networks using this rule
Issue owner: V/Line
Operation affected: Rail: Operations control
Date, status, type
Date: 12 Dec 2016
Status: Not addressed
Type: Recommendation
  Proactive Action
Issue, description, who it affects
Issue: RO-2015-009-SI-01 Driver training
Number: RO-2015-009-SI-01
Description: RO-2015-009-SI-01 :The training and assessment of the driver did not ensure that he had an adequate understanding of the two-position signalling through Marshall. 
Who it affects: Drivers operating on the V/Line network
Issue owner: V/Line
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 12 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-028-SI-02 Operational rules and procedures
Number: RO-2015-028-SI-02
Description: RO-2015-028-SI-02 :The Queensland Rail network rules, procedures and safety manual provided insufficient guidance to identify the magnitude of the potential hazard from a weather event, or define the response when encountering water that had previously overtopped the track and receded or was pooled against the track formation or ballast.
Who it affects: All rail safety workers conducting work on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-028-SI-01 Hazard identification and assessment by rail traffic crew
Number: RO-2015-028-SI-01
Description: RO-2015-028-SI-01 :The Queensland Rail General Operational Safety Manual (MD-10-107) contained insufficient guidance for rail traffic crews to ensure the timely identification and management of a potential hazard (resulting from a weather event) that might affect the safe progress of the train.
Who it affects: All rail transport operators working rolling stock on the rail network
Issue owner: Queensland Rail
Operation affected: Rail: Operations control
Date, status, type
Date: 09 Dec 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-096 -SI-01Compromised separation recovery training
Number: AO-2014-096 -SI-01
Description: AO-2014-096 -SI-01:Compromised separation recovery training deficiencies existed within the Department of Defence at the time of the occurrence, increasing the risk of inappropriate management of aircraft in close proximity. Note: This safety issue was identified as part of ATSB investigation AO-2012-131 as safety issue AO-2012-131-SI-05 and resulted in the ATSB issuing safety recommendation AO‑2012‑131‑SR‑042 on 2 October 2014 (after the ...
Who it affects: All Department of Defence air traffic controllers
Issue owner: Department of Defence
Operation affected: Aviation: Airspace management
Date, status, type
Date: 05 Dec 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: AO-2014-164-SI-01Potential adverse effects of a tip-up canopy opening in-flight
Number: AO-2014-164-SI-01
Description: AO-2014-164-SI-01:In‑flight opening of the tip-up canopy in a number of Van’s Aircraft Inc. models has resulted in varying consequences, including a significant pitch down tendency, increasing the risk of a loss of control. 
Who it affects: Owners of Van’s aircraft fitted with a tip-up canopy
Issue owner: Van’s Aircraft Inc.
Operation affected: Aviation: General aviation
Date, status, type
Date: 25 Nov 2016
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2015-005-SI-03Open stern offshore support vessels
Number: MO-2015-005-SI-03
Description: MO-2015-005-SI-03:Skandi Pacific’s managers had not adequately assessed the risks associated with working on the aft deck of vessels with open sterns, including consideration of engineering controls to minimise water being shipped on the aft deck.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Partially addressed
Type: Proactive Action
  Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2015-005-SI-02Cargo securing procedures
Number: MO-2015-005-SI-02
Description: MO-2015-005-SI-02:Skandi Pacific’s safety management system (SMS) procedures for cargo securing were inadequate. There was no guidance for methods of securing cargo in adverse weather conditions.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-005-SI-01Cargo handling procedures
Number: MO-2015-005-SI-01
Description: MO-2015-005-SI-01:Skandi Pacific’s safety management system (SMS) procedures for cargo handling in adverse weather conditions were inadequate. Clearly defined weather limits when cargo handling operations could be undertaken and trigger points for suspending operations were not defined, including limits for excessive water on deck.
Who it affects: All owners and operators of offshore support vessels
Issue owner: DOF Management, Norway (DOF Management)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Nov 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-04 Towage procedures
Number: MO-2015-002-SI-04
Description: MO-2015-002-SI-04 :Procedures for harbour tugs to meet inbound ships and for their co-ordinated movement in the Fremantle pilotage area were not clearly defined. On 28 February, inadequate co-ordination of the tugs and ineffective communication between Maersk Garonne’s pilot and the tug masters resulted in both tugs, the second one in particular, ...
Who it affects: All those responsible for navigation
Issue owner: Svitzer Australia; Fremantle Ports; Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-03 Contingency planning
Number: MO-2015-002-SI-03
Description: MO-2015-002-SI-03 :Fremantle Pilots’ procedures did not include any contingency plans, including abort points, for risks identified for the pilotage. 
Who it affects: All those responsible for a ship’s safe navigation
Issue owner: Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-02 Passage plan
Number: MO-2015-002-SI-02
Description: MO-2015-002-SI-02 :Fremantle Pilots’ publicly available information to assist ships' masters with preparing a berth to berth passage plan was inadequate and ineffectively implemented. The information provided consisted essentially of a list of waypoints, which was routinely not followed.  
Who it affects: All those responsible for a ship’s safe navigation
Issue owner: Fremantle Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2015-002-SI-01 Bridge resource management
Number: MO-2015-002-SI-01
Description: MO-2015-002-SI-01 :Bridge resource management (BRM) was not effectively implemented on board Maersk Garonne. The ship’s passage plan for the pilotage was inadequate, its bridge team members were not actively engaged in the pilotage and they did not effectively monitor the ship’s passage.
Who it affects: All those responsible for navigation
Issue owner: Maersk Line Ship Management, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 17 Oct 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-028-SI-01Coordination of activities related to pushback
Number: AO-2016-028-SI-01
Description: AO-2016-028-SI-01:The procedures provided to ground and flight crews by Malaysia Airlines Berhad and the towbarless tractor operator did not provide clear guidance or instruction on coordinating activities related to pushback and, in the case of the tractor operator, were informally replaced by local procedures
Who it affects: Air transport ground handling
Issue owner: Malaysia Airlines Berhad and Menzies Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 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: RO-2014-016-SI-02Passenger Train Marker Light Standards
Number: RO-2014-016-SI-02
Description: RO-2014-016-SI-02:The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.
Who it affects: Rail Operators on Melbourne Metropolitan Rail Network
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Other
Date, status, type
Date: 06 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-016-SI-01Permissive Signalling System
Number: RO-2014-016-SI-01
Description: RO-2014-016-SI-01:The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.
Who it affects: Rail Operators on Melbourne Metropolitan Rail Network
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Other
Date, status, type
Date: 06 Jul 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2015-015 SI-02Low rim thickness
Number: RO-2015-015 SI-02
Description: RO-2015-015 SI-02:Despite a number of incidents, Pacific National did not take adequate action, before the derailment, to reduce the risk of wheel defects, especially in light of previously identified contributors such as low rim thickness. 
Who it affects: All owners and operators of heavy haul freight wagons.
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 30 Jun 2016
Status:
Issue, description, who it affects
Issue: RO-2015-015 SI-01Wheel inspection processes
Number: RO-2015-015 SI-01
Description: RO-2015-015 SI-01:The wheel inspection processes and systems were not effective in detecting surface damage or cracks on the R4 wheel on wagon NHIH97081 prior to the wheel failure.
Who it affects: All owners and operators of heavy haul freight wagons
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 30 Jun 2016
Status:
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: MO-2014-009-SI-04Forecast terminology
Number: MO-2014-009-SI-04
Description: MO-2014-009-SI-04:Fremantle Ports’ staff did not understand the significance of some wind and weather terminology used in the BoM forecast. Consequently, port procedures triggered by a BoM ‘gale’ or ‘severe weather’ warning such as preparing the tugs and calling the harbour master were not followed.
Who it affects: Port and ship operators
Issue owner: Fremantle Port Authority (Fremantle Ports)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-009-SI-03Weather event management
Number: MO-2014-009-SI-03
Description: MO-2014-009-SI-03:Fremantle Ports’ procedures for adverse weather were not adequate for weather that could reasonably be expected to occur. Some procedures could not be reasonably implemented and other were not monitored for compliance.
Who it affects: All ships berthed in Fremantle’s Inner Harbour
Issue owner: Fremantle Port Authority (Fremantle Ports)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-009-SI-02Bureau of Meteorology weather warnings
Number: MO-2014-009-SI-02
Description: MO-2014-009-SI-02:The Bureau of Meteorology (BoM) marine forecast title of ‘strong wind warning’ understated the ‘damaging winds’ expected during the ‘severe thunderstorm’. The forecast did not use recognised marine weather terms for wind speed, such as ‘gale force’.
Who it affects: Port, boat and ship operators in Australian coastal waters
Issue owner: Bureau of Meteorology (BoM)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-009-SI-01Fremantle Ports’ risk assessment
Number: MO-2014-009-SI-01
Description: MO-2014-009-SI-01:Fremantle Ports’ assessment of risks associated with a ship contacting the Fremantle Rail Bridge as a result of a breakaway, particularly from berths 11 and 12, was limited. Preventing a breakaway from berths where the wind was likely to be on a ship’s beam had not been considered. Similarly, the ...
Who it affects: All users of Fremantle’s Inner Harbour, including the Fremantle Rail Bridge
Issue owner: Fremantle Port Authority (Fremantle Ports)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 04 May 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-005-SI-04Train / platform clearances
Number: RO-2014-005-SI-04
Description: RO-2014-005-SI-04:Due to the curvature of the track, a wide gap existed between the platform and train at the Heyington Railway Station. There are several stations on the Melbourne metropolitan rail network where wide gaps exist between platforms and trains due to track curvature. These gaps pose a risk to passengers.
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-005-SI-03Standards for train / platform clearances
Number: RO-2014-005-SI-03
Description: RO-2014-005-SI-03:The existing standards stipulated minimum clearances between trains and platforms but did not consider the effect of the resulting gaps with respect to safe accessibility. 
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-005-SI-02Inadequacy of the doors open warning device
Number: RO-2014-005-SI-02
Description: RO-2014-005-SI-02:The train door open/close indicator on the driver’s control console was inadequate as a warning device once the traction interlock had deactivated. 
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: No longer relevant
Type: Recommendation
Issue, description, who it affects
Issue: RO-2014-005-SI-01The train could be moved with the carriage doors open
Number: RO-2014-005-SI-01
Description: RO-2014-005-SI-01:As designed, the traction interlock automatically deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.
Who it affects: Train passengers
Issue owner: Metro Trains Melbourne
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 27 Apr 2016
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-09Ship firefighting cache
Number: MO-2014-008-SI-09
Description: MO-2014-008-SI-09:The large size and weight of the ship firefighting cache made it difficult for the duty Port Hedland volunteer firefighter to transport it to the wharf. 
Who it affects: All agencies charged with shipboard firefighting
Issue owner: Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-08Professional firefighters in Port Hedland
Number: MO-2014-008-SI-08
Description: MO-2014-008-SI-08:The limited professional firefighting capability in Port Hedland restricted the ability to launch an effective response to the fire on board Marigold.   
Who it affects: All agencies charged with shipboard firefighting
Issue owner: Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-07Access control
Number: MO-2014-008-SI-07
Description: MO-2014-008-SI-07:Suitable atmospheric testing equipment was not available in Port Hedland to ensure safe entry to fire-affected spaces on board Marigold. Access to these areas was not controlled until 53 hours after the fire.  
Who it affects: All agencies charged with shipboard firefighting in regional ports
Issue owner: DFES
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Not addressed
Issue, description, who it affects
Issue: MO-2014-008-SI-06Incident control
Number: MO-2014-008-SI-06
Description: MO-2014-008-SI-06:The emergency response plans for a ship fire in Port Hedland did not clearly define transfer of control procedures for successive incident controllers from different organisations or contain standard checklists for their use. 
Who it affects: All agencies charged with shipboard firefighting
Issue owner: BHP Billiton, Pilbara Ports Authority and Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-05International shore connection
Number: MO-2014-008-SI-05
Description: MO-2014-008-SI-05:Port Hedland’s emergency response teams did not use the ship’s international shore fire connection. As a result, Marigold’s fire main was not pressurised with water from ashore.
Who it affects: All persons charged with shipboard firefighting
Issue owner: BHP Billiton and Department of Fire and Emergency Services (DFES)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 20 Apr 2016
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-04Halon system
Number: MO-2014-008-SI-04
Description: MO-2014-008-SI-04:Marigold’s shipboard procedures for crew induction, familiarisation, fire drills and safety training were not effectively implemented. As a result, the ship’s senior officers were not sufficiently familiar with the Halon system’s operation. They did not identify its partial failure and did not activate the override function
Who it affects: All persons responsible for the maintenance of equipment
Issue owner: Korea Leading Company of Ship Management (KLCSM)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-008-SI-03Fixed fire suppression system
Number: MO-2014-008-SI-03
Description: MO-2014-008-SI-03:Marigold’s Halon gas fixed fire suppression system for the engine room was not fully operational. The multiple failures of the system at the time of the fire were not consistent with proper maintenance and testing.  
Who it affects: All persons responsible for the maintenance of equipment
Issue owner: KLCSM
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Apr 2016
Status: Partially addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2014-008-SI-02Ventilation closedown
Number: MO-2014-008-SI-02
Description: MO-2014-008-SI-02:The maintenance of the opening/closing arrangements for Marigold’s engine room fire dampers, ventilators and other openings was inadequate. A number of these could not be closed, resulting in the inability to seal the engine room to contain and suppress the fire.
Who it affects: All persons responsible for the maintenance of equipment
Issue owner: Korea Leading Company of Ship Management (KLCSM)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Apr 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: MO-2014-008-SI-01Fire doors
Number: MO-2014-008-SI-01
Description: MO-2014-008-SI-01:A number of Marigold’s engine room fire doors were held open by wire and/or rope. The open doors allowed the smoke to spread across the engine room and into the accommodation spaces.
Who it affects: All persons responsible for the maintenance of equipment
Issue owner: Korea Leading Company of Ship Management (KLCSM)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Apr 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: MO-2014-012-SI-02 Smoking risk controls
Number: MO-2014-012-SI-02
Description: MO-2014-012-SI-02 :The smoking policy and associated risk controls on board Ocean Drover were not effectively managed. While use of designated smoking rooms was identified as the preferred option, smoking was permitted in cabins. In addition, approved ashtrays were not always used to extinguish and dispose of cigarettes.
Who it affects: All persons responsible for shipboard operations
Issue owner: Korkyra Shipping, Croatia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 Mar 2016
Status: Adequately addressed
Issue, description, who it affects
Issue: MO-2014-012-SI-01 Bridge deck stairwell fire door
Number: MO-2014-012-SI-01
Description: MO-2014-012-SI-01 :Ocean Drover’s bridge deck stairwell fire door was fitted with a holdback hook in contravention of international regulations. The door was hooked open, which allowed the fire to spread to the bridge deck from the deck below. 
Who it affects: All persons responsible for shipboard operations
Issue owner: Korkyra Shipping, Croatia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 11 Mar 2016
Status: Adequately addressed
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: MO-2014-011-SI-01 Implementation of SMS procedures
Number: MO-2014-011-SI-01
Description: MO-2014-011-SI-01 :Cape Splendor’s safety management system (SMS) procedures for working over the side of the ship were not effectively implemented. As a result, the ship’s crew routinely did not take all the required safety precautions when working over the side. Further, they did not consider that any such precautions were necessary ...
Who it affects: All persons responsible for shipboard operations
Issue owner: U-Ming Marine Transport, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 Feb 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-011-NSA-025Safety culture
Number: MO-2014-011-NSA-025
Description: MO-2014-011-NSA-025:The safety culture on board Cape Splendor was not well developed and the ship’s managers had identified it as such. A consequence of this inadequacy was the ineffective implementation of working over the side procedures, including the general belief by its crew that safe work practices applied only when working, ...
Who it affects: All persons responsible for shipboard operations
Issue owner: U-Ming Marine Transport, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 Feb 2016
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
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: RO-2015-005-SI-01Fatigue management
Number: RO-2015-005-SI-01
Description: RO-2015-005-SI-01:Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver. 
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 29 Jan 2016
Status: Not addressed
Type: Proactive Action
  Recommendation
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-2013-026-SI-01 Identification of defect location
Number: RO-2013-026-SI-01
Description: RO-2013-026-SI-01 :When the AK Car was operating in Manual mode, the methods used to identify the location of a defect, and assist track staff to locate the defect could be ineffective in certain scenarios. At the derailment location, there was a consistent offset of about 58 m between the recorded location ...
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-026-SI-02 Track patrols
Number: RO-2013-026-SI-02
Description: RO-2013-026-SI-02 :Track patrol processes were ineffective at detecting and remedying the wide gauge defect at the derailment location. Track patrols were overly reliant on the AK Car geometry recording vehicle to trigger maintenance action on this track geometry defect.  
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-026-SI-03Actions following derailment on 11 September 2013
Number: RO-2013-026-SI-03
Description: RO-2013-026-SI-03:The ARTC response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October.  
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-026-SI-04Rail head wear
Number: RO-2013-026-SI-04
Description: RO-2013-026-SI-04:ARTC processes for managing the condition of the rail were ineffective despite repeated recording of rail head wear by the AK Car, and local knowledge of the worn rail. The rail was worn beyond the rail condemning limits specified within the network code of practice.
Who it affects: Track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2016
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-010-SI-02Local Appendix Unit – North V3
Number: RO-2015-010-SI-02
Description: RO-2015-010-SI-02:The ARTC Local Appendix Unit North – Volume 3 did not reflect current equipment installation arrangements for E Frame at Singleton.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 06 Jan 2016
Status: Adequately addressed
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: RO-2015-007-SI-03Train pathing
Number: RO-2015-007-SI-03
Description: RO-2015-007-SI-03:The practice of pathing a following train onto a line occupied by a preceding train, when an alternate route was available and not obstructed, presented an elevated level of risk.
Who it affects: All rail transport operators throughout Australia
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Dec 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-007-SI-04Pre-warning train driver of occupied track
Number: RO-2015-007-SI-04
Description: RO-2015-007-SI-04:The practice of pathing a following train onto the same line occupied by a preceding train, without pre-warning the driver regarding the train ahead, presented an elevated level of risk.
Who it affects: All rail transport operators throughout Australia
Issue owner: Australian Rail Track Corporation and SCT Logistics
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Dec 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-007-SI-05National Train Communications System (NTCS) – Broadcast communications
Number: RO-2015-007-SI-05
Description: RO-2015-007-SI-05:The design of the NTCS in screening Adelaide metro broadcast communications prevented the driver of 2MP9 from gaining an appreciation of activities close to his area of operation, in particular the position of train 2MP1 along the Mile End main line.
Who it affects: All rail transport operators throughout Australia
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Dec 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2015-007-SI-01End of train conspicuity
Number: RO-2015-007-SI-01
Description: RO-2015-007-SI-01:Vegetation and a low fence adjacent the Mile End crossing loop partially obscured the view that the crew of train 2MP9 had of the empty flat wagons at the rear of train 2MP1.
Who it affects: All rail transport operators throughout Australi
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Dec 2015
Status: Not addressed
Type: Proactive Action
  Recommendation
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: RO-2015-003-SI-01 Safeworking systems and processes
Number: RO-2015-003-SI-01
Description: RO-2015-003-SI-01 :There were no formal systems in place to manage the accepted practice of Protection Officers leaving a work site to return a Track Warrant and Train Staff, prior to ceasing works, off-tracking and ensuring the line was clear. This practice led to the informal delegation of responsibility for ensuring the ...
Who it affects: V/Line Pty Ltd
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 09 Dec 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-001-SI-001Wheel slip protection indicator light
Number: RO-2014-001-SI-001
Description: RO-2014-001-SI-001:Drivers are desensitised to the wheel slip protection indicator light activations through its regular activation in response to momentary losses of adhesion. This, coupled with the inadequate warning provided by the TMS, may result in delayed reaction in response to activations that need driver intervention.
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Rolling stock
Date, status, type
Date: 03 Dec 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-001-SI-002 Reporting and Verbal Communications
Number: RO-2014-001-SI-002
Description: RO-2014-001-SI-002 :Reporting and communications were not carried out in accordance with Sydney Trains rules and procedures, so that key employees in the Rail Management Centre received delayed and/or partial information and allowed the train to continue in service.
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Operations control
Date, status, type
Date: 03 Dec 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-001-NSA-025Rail Resource Management
Number: RO-2014-001-NSA-025
Description: RO-2014-001-NSA-025:Key staff had not been trained in Rail Resource Management. 
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Operations control
Date, status, type
Date: 03 Dec 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-001-SI-004Incident Rail Commander Role
Number: RO-2014-001-SI-004
Description: RO-2014-001-SI-004:The lack of an appointed Officer in Charge of the incident site prior to the arrival of an Incident Rail Commander led to a fragmented response with no single employee having a recognised leadership role on site. 
Who it affects: Sydney Trains
Issue owner: Sydney Trains
Operation affected: Rail: Operations control
Date, status, type
Date: 03 Dec 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
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: RO-2014-014-SI-01Detection of rail defects
Number: RO-2014-014-SI-01
Description: RO-2014-014-SI-01:The scheduled ultrasonic tests conducted in November 2013 on the 80 lb/yd rail between Northgate and Alice Springs had been ineffective in detecting and quantifying the significant defects present at 1036.541 km and 975.244 km locations.
Who it affects: All rail track managers
Issue owner: Genesee & Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 28 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-014-SI-02Special locations
Number: RO-2014-014-SI-02
Description: RO-2014-014-SI-02:Contrary to the requirements of procedure IN-PRC-020, GWA had not established a list of specific locations known to have an increased likelihood of failure, such that particular attention may be applied in those locations during inspections.
Who it affects: All rail track managers
Issue owner: Genesee & Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 28 Oct 2015
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-020-SI-01The insulated rail joints were incorrectly placed
Number: RO-2013-020-SI-01
Description: RO-2013-020-SI-01:The placement of the insulated rail joints adjacent to signal DYN150 was not in accordance with the ARTC engineering procedure ESC-07-01.
Who it affects: Network Control
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 16 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-020-SI-02Communication protocols at the Melbourne Freight Terminal
Number: RO-2013-020-SI-02
Description: RO-2013-020-SI-02:The practice of using a third party (the shunt planner) to facilitate communication between Network Control Officers and train drivers at the Melbourne Freight Terminal prevented an effective response to the emergency.
Who it affects: Network Control
Issue owner: Pacific National
Operation affected: Rail: Operations control
Date, status, type
Date: 16 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-018-SI-01 Maintenance, defect monitoring and reporting as per CoP
Number: RO-2014-018-SI-01
Description: RO-2014-018-SI-01 :Track defect monitoring and reporting was not being conducted as specified in the Westrail Narrow Gauge Mainline Code of Practice, limiting the awareness of the deteriorating track condition and the need for reassessment of track operating limits.
Who it affects: Rail infrastructure maintainers
Issue owner: Transfield Services
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-003-SI-01Planned and other maintenance
Number: MO-2014-003-SI-01
Description: MO-2014-003-SI-01:The poor condition of Royal Pescadores’ anchoring equipment was indicative of inadequate maintenance. The shipboard management team were not aware of the equipment’s maintenance history nor able to provide relevant documents from the ship’s planned maintenance system. 
Who it affects: All persons charged with maintaining equipment
Issue owner: Shih Wei Navigation
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-003-SI-02Bitter end securing arrangement
Number: MO-2014-003-SI-02
Description: MO-2014-003-SI-02:The International Association of Classification Societies (IACS) recommendation for having a means of slipping the anchor cable bitter outside the chain locker had not been provided on board Royal Pescadores. Further, the ship’s classification society, ClassNK, does not consider that the IACS recommended slipping arrangement is necessary for reducing safety ...
Who it affects: All persons responsible for ship and crew safety
Issue owner: Shih Wei Navigation and ClassNK
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Oct 2015
Status: Partially addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2014-003-SI-03Weather related matters
Number: MO-2014-003-SI-03
Description: MO-2014-003-SI-03:While the Fremantle vessel traffic service (VTS) operational procedures were aimed at having precautionary measures in place for adverse weather conditions, the triggers specified in the procedures only referred to BoM-issued severe weather and gale warnings. As no wind speed limits were specified, the gale force winds experienced at Fremantle ...
Who it affects: All ships operating in the Port of Fremantle
Issue owner: Fremantle Port Authority (Fremantle Ports)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-018-SI-02 Oversight of Infrastructure Maintenance
Number: RO-2014-018-SI-02
Description: RO-2014-018-SI-02 :The rail transport operator (GWA) had not maintained sufficient oversight of the activities of the rail infrastructure manager (Transfield Services), allowing the track to deteriorate to a level where trains could not be reliably run in a safe manner.
Who it affects: Rail network managers and owners
Issue owner: Genesee & Wyoming Australia
Operation affected: Rail: Infrastructure
Date, status, type
Date: 09 Oct 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-024-SI-01Management of lineside foliage
Number: RO-2014-024-SI-01
Description: RO-2014-024-SI-01:V/Line’s process for the inspection of level crossing sighting did not provide explicit instructions for the identification and removal of problem vegetation.
Who it affects: All road users and operators of trains on trackage owner or managed by V/Line.
Issue owner: V/Line
Operation affected: Rail: Operations control
Date, status, type
Date: 25 Sep 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-007-SI-01Loading rules and procedures
Number: RO-2014-007-SI-01
Description: RO-2014-007-SI-01:The Pacific National freight loading manual, and application of it, was ineffective at preventing loadshift with rod-in-coil product.
Who it affects: All transporters of rod-in-coil product
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 23 Sep 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2014-021-SI-01Deficient handover process
Number: RO-2014-021-SI-01
Description: RO-2014-021-SI-01:There was a breakdown in the NCO handover process used at Morisset which resulted in ASB being granted to the Protection Officer at Warnervale without the exact location of trains being properly established, signals V8 and V6 being set back to stop and blocking facilities applied in accordance with Network ...
Who it affects: Users the Sydney Trains Network Rules and Procedures
Issue owner: Sydney Trains
Operation affected: Rail: Infrastructure
Date, status, type
Date: 17 Sep 2015
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2015-002-SI-01 Documented instructions
Number: RO-2015-002-SI-01
Description: RO-2015-002-SI-01 :The Public Transport Authority of Western Australia did not have documented instructions to ensure a consistent and safe approach to maintaining automatic pedestrian crossing equipment.
Who it affects: All owners, operators and maintainers of railway infrastructure.
Issue owner: Public Transport Authority of Western Australia
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Sep 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: MO-2014-006-SI-01Proper lookout
Number: MO-2014-006-SI-01
Description: MO-2014-006-SI-01:Kota Wajar’s safety management system procedures with regard to posting a dedicated lookout were not effectively implemented.
Who it affects: All persons responsible for navigation
Issue owner: Pacific International Lines, Singapore
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 30 Jul 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-006-SI-02Passage planning
Number: MO-2014-006-SI-02
Description: MO-2014-006-SI-02:Brisbane Marine Pilots’ standard passage plan and master-pilot exchange did not ensure that a ship’s bridge team is provided adequate information with respect to local traffic and areas where attention must be paid to other vessels, including small craft.
Who it affects: All persons responsible for navigation
Issue owner: Brisbane Marine Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 30 Jul 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-006-SI-03Collisions between ships and small vessels
Number: MO-2014-006-SI-03
Description: MO-2014-006-SI-03:Over the past 26 years, investigations into 41 collisions between trading ships and small vessels on the Australian coast have identified that not maintaining a proper lookout and taking early avoiding action, in accordance with the collision regulations, has been a consistent and continuing contributor to such collisions.
Who it affects: All persons responsible for navigation
Issue owner: Master, owners, operators and skippers of all vessels
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 30 Jul 2015
Status: Partially addressed
Type: Safety Advisory Notice
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: RO-2012-011-SI-01The management of fatigue impairment
Number: RO-2012-011-SI-01
Description: RO-2012-011-SI-01:SBR’s fatigue-management processes were ineffective in identifying the fatigue impairment experienced by the driver leading up to, and at the time of the occurrence.
Who it affects: Rail operators and rail safety workers
Issue owner: Specialised Bulk Rail Pty Ltd
Operation affected: Rail: Freight
Date, status, type
Date: 22 Jun 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-011-SI-02Communication of ‘safety critical information’
Number: RO-2012-011-SI-02
Description: RO-2012-011-SI-02:The ARTC communication protocols did not provide the NCO adequate guidance with respect to standardised phraseology to ensure messages are clear and unambiguous.
Who it affects: Rail operators and rail safety workers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 22 Jun 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-011-SI-03The management of conditional proceed authorities
Number: RO-2012-011-SI-03
Description: RO-2012-011-SI-03:The procedures in the ARTC CoP for the use and verification of a conditional proceed authority were ineffective in mitigating the risk to the effectiveness of that authority arising from human error.
Who it affects: Rail operators and rail safety workers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 22 Jun 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: RO-2013-002-SI-02Track Stability Maintenance Plan
Number: RO-2013-002-SI-02
Description: RO-2013-002-SI-02:There was no Track Stability Management Plan in place for the section of track where the buckle developed – as was required by the ARTC’s CoP.
Who it affects: All track maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 26 May 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-003-SI-001Rail creep management
Number: RO-2014-003-SI-001
Description: RO-2014-003-SI-001:V/Line’s organisational processes for responding to and rectifying rail creep defects did not ensure that all such defects were addressed in a timely way.
Who it affects: All owners of rail infrastructure
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 20 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-002-SI-01Lack of visual indication for the resetting of the release segment
Number: MO-2014-002-SI-01
Description: MO-2014-002-SI-01:While the design of the on-load release system allowed the reset position of the hook to be visually confirmed, it did not allow for visual confirmation that the release segment and mechanism had been correctly reset. Consequently, the hook device could appear to be properly reset when it was not.
Who it affects: All ships with this type of on-load release arrangement
Issue owner: Jiangsu Jiaoyan Marine Equipment Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 May 2015
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2014-002-SI-02On-load release safety pin
Number: MO-2014-002-SI-02
Description: MO-2014-002-SI-02:An equivalent, alternative arrangement to the safety pin had not been provided to prevent inadvertent tripping of the freefall lifeboat’s on-load release during routine operations, such as inspections and maintenance.
Who it affects: All ships with this type of on-load release arrangement
Issue owner: Jiangsu Jiaoyan Marine Equipment Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 May 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
  Proactive Action
  Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2014-002-SI-03Simulation wire calculation
Number: MO-2014-002-SI-03
Description: MO-2014-002-SI-03:The manufacturer’s calculations did not take into account the shock load imposed on the simulation wires or the lifeboat and launching frame mounting points.
Who it affects: All ships with this type of launch simulation system
Issue owner: Jiangsu Jiaoyan Marine Equipment Company
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 May 2015
Status: Safety action pending
Type: Proactive Action
  Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2014-002-SI-04Simulation wire approval by a recognized organization
Number: MO-2014-002-SI-04
Description: MO-2014-002-SI-04:The Recognized Organization’s process for the approval of the simulation wires for ‘maintenance and testing’ had not taken into account the shock loading that would be experienced during testing.
Who it affects: All ships with this type of launch simulation system
Issue owner: Bureau Veritas and the International Association of Classification Societies
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 19 May 2015
Status: Safety action pending
Type: Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2014-013-SI-01Safe transition of dual gauge turnouts (Preliminary report)
Number: RO-2014-013-SI-01
Description: RO-2014-013-SI-01:Inherent to the design of many dual gauge turnouts, is a region of reduced wheel rim contact on the broad gauge switch blade (rail head) through the transfer area. In circumstances where the switch blade is insufficiently restrained, and where the passing train has a narrow (127 mm) wheel rim ...
Who it affects: All rail operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status:
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2014-013-SI-02Design of turnouts – MYD882 and MYD887
Number: RO-2014-013-SI-02
Description: RO-2014-013-SI-02:The design of the VCA type 37 mixed gauge turnouts (MYD882 and MYD887) was such that they were not suitable for use by rolling stock with a 127 mm rimmed wheel.
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-013-SI-03Contract approval process
Number: RO-2014-013-SI-03
Description: RO-2014-013-SI-03:Contract documentation and specifications within the Services and Supply Umbrella Agreement were generic and did not adequately specify the intended purpose of the type 37 turnout.
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-013-SI-04Provisional type approval process
Number: RO-2014-013-SI-04
Description: RO-2014-013-SI-04:The VCA type 37 turnout design and V/Line’s provisional type approval process did not fully identify the subtle design changes inherent with the VCA type 37 turnout in determining testing, commissioning and validation needs.
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-013-SI-05Testing of turnouts MYD882 and MYD887
Number: RO-2014-013-SI-05
Description: RO-2014-013-SI-05:The physical testing and commissioning regime for the VCA type 37 turnout did not require the use of standard gauge trains with 127 mm rimmed wheels.
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-013-SI-06Inspection of turnout MYD882 and train wheels
Number: RO-2014-013-SI-06
Description: RO-2014-013-SI-06:V/Line’s processes for responding to the report by the driver of train ST21 did not limit or prevent the subsequent movement of train ST24 before checks had been carried out to identify and assess any potential track and/or rolling stock issue(s).
Who it affects: All rail transport operators throughout Australia
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 May 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-010-SI-01 Track inspection regime
Number: RO-2013-010-SI-01
Description: RO-2013-010-SI-01 :The track inspection regime did not identify the deteriorated rail condition at the O’Tooles Road level crossing. The regime placed an over-reliance on ultrasonic testing and did not include sufficient supplementary systems for monitoring the condition of buried track at unsealed level crossings.
Who it affects: Owners and operators of rail infrastructure
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 29 Apr 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-010-SI-02 Ultrasonic inspection
Number: RO-2013-010-SI-02
Description: RO-2013-010-SI-02 :The ultrasonic testing regime was not effective in consistently identifying corrosion and wasting of the rail web at unsealed level crossings.
Who it affects: Owners and operators of rail infrastructure.
Issue owner: Speno
Operation affected: Rail: Infrastructure
Date, status, type
Date: 29 Apr 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-010-SI-03 Construction of level crossing at unsealed roads
Number: RO-2013-010-SI-03
Description: RO-2013-010-SI-03 :The method of constructing crossings at unsealed roads heightened the potential for corrosion and track degradation and limited the opportunity for effective visual inspection. The network standard for crossing construction did not directly address the particular challenges of unsealed roads.
Who it affects: Owners and operators of rail infrastructure.
Issue owner: V/Line
Operation affected: Rail: Infrastructure
Date, status, type
Date: 29 Apr 2015
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-012-SI-01Assessment of the suitability of second-hand components
Number: RO-2014-012-SI-01
Description: RO-2014-012-SI-01:GWA had no documented system in place to assess the suitability of second-hand components for re-use.
Who it affects: All rail infrastructure managers
Issue owner: Genesee Wyoming Australia (GWA)
Operation affected: Rail: Infrastructure
Date, status, type
Date: 28 Apr 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-008-SI-01WOE class wagon, dynamic performance
Number: RO-2014-008-SI-01
Description: RO-2014-008-SI-01:When travelling at speeds near 90 km/h on track having particular track irregularities, the WOE class wagons appear to be susceptible to harmonic oscillations of sufficient magnitude to produce wheel unloading, flange climb and derailment.
Who it affects: All rail transport operators throughout Australia
Issue owner: Aurizon and Brookfield Rail
Operation affected: Rail: Rolling stock
Date, status, type
Date: 26 Mar 2015
Status: Safety action pending
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2014-008-SI-02Increasing train speed
Number: RO-2014-008-SI-02
Description: RO-2014-008-SI-02:After re-railing the track, permitted train speed was increased without due consideration of the effects of cyclic track irregularities on the dynamic performance of the WOE class wagon.
Who it affects: All rail transport operators throughout Australia
Issue owner: Brookfield Rail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 26 Mar 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-008-SI-03Driver reporting and cab ride arrangements
Number: RO-2014-008-SI-03
Description: RO-2014-008-SI-03:The frequency of driver reporting and locomotive cab rides by track inspectors had been insufficient for identifying rough track through the derailment site.
Who it affects: All rail transport operators throughout Australia
Issue owner: Aurizon and Brookfield Rail
Operation affected: Rail: Rolling stock
Date, status, type
Date: 26 Mar 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-008-SI-04Train braking performance
Number: RO-2014-008-SI-04
Description: RO-2014-008-SI-04:The loss of brake pipe integrity during the derailment event did not result in the train brakes automatically activating.
Who it affects: All rail transport operators throughout Australia
Issue owner: Aurizon and Brookfield Rail
Operation affected: Rail: Rolling stock
Date, status, type
Date: 26 Mar 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-006-SI-01 Response to flood event investigations
Number: RO-2014-006-SI-01
Description: RO-2014-006-SI-01 :The ARTC’s processes for developing and implementing changes to operational procedures as a result of incident investigation findings were ineffective at mitigating the risk of future similar incidents.
Who it affects: Rail network managers and train operators
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 25 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-006-SI-02 Management of weather warnings
Number: RO-2014-006-SI-02
Description: RO-2014-006-SI-02 :The ARTC did not have a comprehensive system in place to identify and actively manage risks associated with severe weather events that were likely to affect the safety of their rail network.
Who it affects: Rail network managers and train operators
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 25 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-006-SI-03 Infrastructure flood management
Number: RO-2014-006-SI-03
Description: RO-2014-006-SI-03 :A register for recording ‘special locations’ in accordance with the ARTC Engineering (Track & Civil) Code of Practice - Section 10 – Flooding, had not been established to manage track infrastructure prone to flood damage.
Who it affects: Rail network managers and train operators
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 25 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-015-SI-01Genesee & Wyoming Australia procedures for acceptance of dangerous freight
Number: RO-2014-015-SI-01
Description: RO-2014-015-SI-01:Genesee & Wyoming Australia had no procedure in place to verify (either in total or by random selection) that the nature or condition of freight provided by their customers, complied with their Standard Condition of Carriage.
Who it affects: Rail operators
Issue owner: Genesee & Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 24 Mar 2015
Status: Safety action pending
Type: Proactive Action
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: RO-2013-018-SI-01Insufficient guidance in Absolute Signal Blocking
Number: RO-2013-018-SI-01
Description: RO-2013-018-SI-01:Rule NWT 308 Absolute Signal Blocking and procedure NPR703 Using Absolute Signal Blocking did not provide any guidance on acceptable methods for determining the location of rail traffic in the section or confirming the clearance of rail traffic past a proposed work location.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-018-SI-02No forms or checklists
Number: RO-2013-018-SI-02
Description: RO-2013-018-SI-02:There were no forms or checklists to provide practical guidance for completing the steps required to implement Absolute Signal Blocking (ASB) or to provide an auditable record of the process.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-018-SI-03Differences in identifying trains
Number: RO-2013-018-SI-03
Description: RO-2013-018-SI-03:Differences exist in the way signallers and Protection Officers (POs) identify trains to each other.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-018-SI-04Infrastructure not marked on ATRICS screen
Number: RO-2013-018-SI-04
Description: RO-2013-018-SI-04:Not all major infrastructure was marked on the ATRICS screens for the North Shore panel.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-018-SI-05Auditing not effective
Number: RO-2013-018-SI-05
Description: RO-2013-018-SI-05:The Sydney Trains regime for auditing worksite protection arrangements was not effective in identifying emerging trends or safety critical issues when using Absolute Signal Blocking (ASB).
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 02 Mar 2015
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-028-SI-01Special locations
Number: RO-2013-028-SI-01
Description: RO-2013-028-SI-01:Union Reef was not treated as a special location as defined in the ARA Code of Practice for the Australian Rail Network.
Who it affects: All owners and operators of track infrastructure
Issue owner: Genesee and Wyoming Australia
Operation affected: Rail: Infrastructure
Date, status, type
Date: 17 Feb 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-028-SI-02Guidelines
Number: RO-2013-028-SI-02
Description: RO-2013-028-SI-02:The GWA guidance does not provide clear and unambiguous information for train crews on acceptable points approach speeds where sighting distance is reduced
Who it affects: All owners and operators of freight trains
Issue owner: Genesee and Wyoming Australia
Operation affected: Rail: Infrastructure
Date, status, type
Date: 17 Feb 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-028-SI-03Train crew distraction and priorities
Number: RO-2013-028-SI-03
Description: RO-2013-028-SI-03:The train crew had conflicting responsibilities distracting them from the safety critical task of driving. GWA did not have specific policies and procedures to define responsibilities of train crews approaching safety critical phases of operation.
Who it affects: All owners and operators of freight trains
Issue owner: Genesee and Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 17 Feb 2015
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2014-001-SI-02Manufacturer’s instructions
Number: MO-2014-001-SI-02
Description: MO-2014-001-SI-02:The manufacturer’s instruction manual for Seven Seas Voyager’s waste incinerator contained no specific instructions for ash grate maintenance or replacement. Such instructions would have provided useful information for the ship’s crew to plan and safely complete periodic ash grate maintenance.
Who it affects: All persons charged with maintaining equipment
Issue owner: ISIR Impianti Srl
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 23 Jan 2015
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-007-SI-01Track maintenance
Number: RO-2013-007-SI-01
Description: RO-2013-007-SI-01:The ARTC’s inspection and maintenance practices were ineffective at identifying and correcting the deteriorating condition of track infrastructure exhibiting accelerated wear, such as 38A points at Spencer Junction.
Who it affects: All rail safety workers and rolling stock operators
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 14 Jan 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-027-SI-01Train Control System – design and screen display
Number: RO-2013-027-SI-01
Description: RO-2013-027-SI-01:The Train Control System permitted the NCO to set an unviable route for the train and then displayed it as viable. The train control system alarm designed to alert the NCO to the setting of an unviable route was nullified by the absence of gauge detection.    
Who it affects: ARTC network controllers
Issue owner: Australian Rail Track Corporation (ARTC)
Operation affected: Rail: Operations control
Date, status, type
Date: 13 Jan 2015
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-027-SI-02Flaw in Caution Order form
Number: RO-2013-027-SI-02
Description: RO-2013-027-SI-02:A caution order instrument was used that lacked a specific requirement for train crews to check the points along their route. This requirement becomes critical under circumstances of signalling system degradation.
Who it affects: ARTC network controllers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 13 Jan 2015
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-012-SI-01Planned maintenance
Number: MO-2013-012-SI-01
Description: MO-2013-012-SI-01:HC Rubina’s electronic planned maintenance system did not contain any instructions to ensure that the shaft alternator flexible coupling was maintained in accordance with the manufacturer’s requirements.
Who it affects: All ships
Issue owner: IMM Shipping
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Nov 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2013-012-SI-02Defect reporting
Number: MO-2013-012-SI-02
Description: MO-2013-012-SI-02:The ship’s managers did not have effective systems to ensure that the defective control system for the controllable pitch propeller was reported to the relevant organisations as required. Consequently, Brisbane’s vessel traffic services, pilotage provider and the pilot remained unaware of the defect and could not consider it in their risk ...
Who it affects: All ships
Issue owner: IMM Shipping
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Nov 2014
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2013-012-SI-03Port entry procedures – Defect notification
Number: MO-2013-012-SI-03
Description: MO-2013-012-SI-03:The ship’s agent’s information questionnaire did not ask for all of the information required to complete the QSHIPS booking form and ensure that defects were reported.
Who it affects: Port operations and vessel’s under pilotage
Issue owner: Asiaworld Shipping Services and Maritime Safety Queensland
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 14 Nov 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  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: RO-2014-010-SI-01Maintenance procedures
Number: RO-2014-010-SI-01
Description: RO-2014-010-SI-01:The procedures for locomotive inspection and maintenance were not effective at identifying and addressing continuing fuel leakage problems on this type of fuel filter assembly.
Who it affects: All owners and operators of locomotives
Issue owner: Pacific National and Downer EDI Rail
Operation affected: Rail: Rolling stock
Date, status, type
Date: 31 Oct 2014
Status: Adequately addressed
Type: 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: RO-2013-008-SI-01Sighting restrictions due to road-to-rail angle
Number: RO-2013-008-SI-01
Description: RO-2013-008-SI-01:For eastbound road users approaching the B. McCann Road level crossing along the left-side of the road, the view to the track was restricted due to the acute road-to-rail interface.  This was particularly problematic for trucks with the viewing opportunity to the left limited to the cab’s passenger-side window. 
Who it affects: Users of B. McCann Road level crossing
Issue owner: Cumco Gypsum Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-008-SI-02Rail operator inaction to address identified sighting issues
Number: RO-2013-008-SI-02
Description: RO-2013-008-SI-02:V/Line did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the rail operator in 2009. 
Who it affects: Users of level crossings in Victoria
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-04Road incline on approach to level crossing
Number: RO-2013-008-SI-04
Description: RO-2013-008-SI-04:The road incline on the west-side approach to the crossing increased the time required for loaded trucks to transit the crossing.
Who it affects: Users of B. McCann Road level crossing
Issue owner: Cumco Gypsum Pty Ltd
Operation affected: Rail: Other
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-008-SI-05Crossing protection inconsistent with available sighting
Number: RO-2013-008-SI-05
Description: RO-2013-008-SI-05:The give-way protection installed at the crossing was inconsistent with the available sighting distances on both approaches to the crossing.  Sighting was affected by vegetation, embankments formed by a rail cutting and the curved road approaches. 
Who it affects: Users of B. McCann Road level crossing
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-07ALCAM crossing assessment processes
Number: RO-2013-008-SI-07
Description: RO-2013-008-SI-07:When the crossing was last surveyed under the ALCAM program, the measurement of the road angle resulted in an overestimation of the acute road-to-rail interface angle.  The implication of overestimating the acute interface angle is that sighting deficiencies may be underestimated or not identified.
Who it affects: Stakeholders associated with risk assessment of level crossings
Issue owner: VicTrack
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-08Inconsistency between permitted and published line speed
Number: RO-2013-008-SI-08
Description: RO-2013-008-SI-08:There existed an inconsistency between the track speed used for crossing assessment and permitted train speeds. The ALCAM process used a train speed equal to the track line speed, whereas V/Line systems for evaluating driver behaviour permitted an exceedence of line speed by up to 10 km/h for short distances. 
Who it affects: Stakeholders associated with risk assessment of level crossings
Issue owner: VicTrack
Operation affected: Rail: Other
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-06Level crossing stakeholder consultation
Number: RO-2013-008-SI-06
Description: RO-2013-008-SI-06:The level crossing safety coordination processes did not involve a key stakeholder, the gypsum mine owner, who had knowledge of the changing traffic profile.  The mine owner was aware of the increasing numbers of heavy vehicles using B. McCann Road since 2010 and the associated changing risk profile of the ...
Who it affects: Stakeholders associated with level crossings
Issue owner: V/Line Pty Ltd
Operation affected: Rail: Infrastructure
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-008-SI-03Shire inaction to address identified sighting issues
Number: RO-2013-008-SI-03
Description: RO-2013-008-SI-03:Gannawarra Shire did not adequately address level crossing sighting issues at B. McCann Road acknowledged by the Shire in 2009. 
Who it affects: Users of level crossings in Gannawarra Shire
Issue owner: Gannawarra Shire
Operation affected: Rail: Other
Date, status, type
Date: 07 Oct 2014
Status: Adequately addressed
Type: Recommendation
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: MO-2013-011-SI-01Roles and Responsibilities
Number: MO-2013-011-SI-01
Description: MO-2013-011-SI-01:Bosphorus’ safety management system provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage.
Who it affects: All persons charged with navigating a vessel during pilotage
Issue owner: Universal Shipping
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 22 Sep 2014
Status: Not addressed
Type: Recommendation
Issue, description, who it affects
Issue: High risk areas of pilotage MO-2013-011-SI-02
Number: High risk areas of pilotage
Description: High risk areas of pilotage :Brisbane Marine Pilots’ ‘Port of Brisbane Passage Plan’ did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
Who it affects: All persons charged with navigating a vessel during pilotage
Issue owner: Brisbane Marine Pilots
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 22 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-011-SI-03High risk areas of pilotage
Number: MO-2013-011-SI-03
Description: MO-2013-011-SI-03:Bosphorus’ safety management system did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.
Who it affects: All persons charged with navigating a vessel during pilotage
Issue owner: Universal Shipping
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 22 Sep 2014
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-017-SI-02Non-compliance with repeat back provisions
Number: RO-2013-017-SI-02
Description: RO-2013-017-SI-02:There were non-compliances to the repeat back provision because it was viewed as onerous under certain Local Possession Authorities (LPAs). An opportunity exists to review rule non-conformance with the implementation of LPAs.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 19 Sep 2014
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-017-SI-03Production, validation, customer review and distribution of STNs
Number: RO-2013-017-SI-03
Description: RO-2013-017-SI-03:Sydney Trains validation processes were not effective in detecting errors in Special Train Notice (STN) 1004 prior to the Local Possession Authority (LPA) implementation.
Who it affects: All rail operators
Issue owner: Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 19 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-06Drug & alcohol management
Number: RO-2012-006-SI-06
Description: RO-2012-006-SI-06:Transfield did not have adequate systems in place to ensure workers were not adversely affected by drugs or alcohol while conducting safety related work in a remote work environment.
Who it affects: Rail – Rail maintenance
Issue owner: Transfield Services Australia
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-02Road-rail vehicle maintenance regime
Number: RO-2012-006-SI-02
Description: RO-2012-006-SI-02:The maintenance regime for Hino TS63 was inadequate and did not account for the accelerated wear and tear on the vehicle when used as a road-rail vehicle.
Who it affects: Track maintenance staff
Issue owner: Transfield Services Australia
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-04Oversight
Number: RO-2012-006-SI-04
Description: RO-2012-006-SI-04:Transfield did not provide oversight sufficient to identify and rectify the non-compliant work practices in the road-rail vehicle operation involved in this occurrence.
Who it affects: Transfield Services Australia
Issue owner:
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-03Training
Number: RO-2012-006-SI-03
Description: RO-2012-006-SI-03:Transfield’s training regime did not ensure that the track workers involved in this occurrence were trained in new or updated work practices relating to road-rail vehicle operations. Similarly, relevant amended procedures, safety bulletins and alerts had not been effectively promulgated to these employees.
Who it affects: Rail – Rail maintenance
Issue owner: Transfield Services Australia
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-006-SI-05Road-rail vehicle national standards
Number: RO-2012-006-SI-05
Description: RO-2012-006-SI-05:The absence of a national standard that addresses the design, fitment and maintenance of rail guidance equipment and the safety performance for road-rail vehicles while on-rail, increases the risks associated with operating road-rail vehicles.
Who it affects: Rail – Owners and operators of road-rail vehicles
Issue owner: Transfield Services Australia, the Office of National Rail Safety Regulator and the Rail Industry Safety Standards Board
Operation affected: Rail: Other
Date, status, type
Date: 15 Sep 2014
Status:
Type: Proactive Action
  Proactive Action
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: RO-2013-009-SI-02Train control system screen display – incompatible gauge warning
Number: RO-2013-009-SI-02
Description: RO-2013-009-SI-02:When train 9501 approached signal DYN114, which was displaying a Stop indication, there was minimal indication to the network control officer that the train gauge and the selected route were incompatible.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-03Configuration of dual-gauge points assembly
Number: RO-2013-009-SI-03
Description: RO-2013-009-SI-03:The configuration of the dual-gauge points assembly led to a truncated broad-gauge rail in one of the turnout directions.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-04Route knowledge information to train drivers
Number: RO-2013-009-SI-04
Description: RO-2013-009-SI-04:The train operator’s Route Knowledge Package did not include track layout diagrams, or specific information warning of the existence of dual-gauge turnouts where track terminated in one direction.
Who it affects: Rail operators
Issue owner: Pacific National
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-009-SI-05 Indicating the termination of broad-gauge track
Number: RO-2013-009-SI-05
Description: RO-2013-009-SI-05 :There was no warning indication at signal DYN114 to warn train crews that the broad-gauge rail terminated in the straight-ahead direction.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-06Authorising movement past a signal at stop
Number: RO-2013-009-SI-06
Description: RO-2013-009-SI-06:The procedures and guidance documentation for authorising movement past signals displaying a Stop indication was ambiguous.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-07Caution Orders - validating train and route compatibility
Number: RO-2013-009-SI-07
Description: RO-2013-009-SI-07:The process undertaken by the network control officer for issuing a Caution Order does not require validation of compatibility between the train gauge and the established route.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 04 Sep 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-009-SI-01Train control system screen display – route information
Number: RO-2013-009-SI-01
Description: RO-2013-009-SI-01:The train control system screen display provided no direct indication to the network control officer that one section of the established route was dual-gauge and another section single-gauge.
Who it affects: Infrastructure managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 04 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-01Degraded rail joint was not detected
Number: RO-2013-021-SI-01
Description: RO-2013-021-SI-01:V/Line's track inspection regime did not identify the degraded condition of the mechanical rail joints.
Who it affects: All operators of freight trains and infrastructure managers.
Issue owner: V/Line Regional Network and Access
Operation affected: Rail: Infrastructure
Date, status, type
Date: 01 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: RO-2013-019-SI-01Inconsistency in defining responsibilities for the refuelling of locomotives
Number: RO-2013-019-SI-01
Description: RO-2013-019-SI-01:The instructions relating to the arranging of refuelling at Parkeston contained in the Pacific National train management plan and the intermodal procedures manual were inconsistent.
Who it affects: All rail safety workers and rolling stock operators
Issue owner: Pacific National Pty Ltd
Operation affected: Rail: Freight
Date, status, type
Date: 07 Jul 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-010-SI-01Crane warning devices
Number: MO-2013-010-SI-01
Description: MO-2013-010-SI-01:The gantry crane in motion warning light nearest to the assistant electrician’s location was not operating and the warning sirens were not audible from his location. As a result, he was not provided with either a visual or audible warning of the crane’s movement.
Who it affects: All ship owners, operators and seafarers
Issue owner: Gearbulk Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 16 Jun 2014
Status: Adequately addressed
Issue, description, who it affects
Issue: MO-2013-010-SI-02Crew familiarisation
Number: MO-2013-010-SI-02
Description: MO-2013-010-SI-02:The on board familiarisation process did not ensure that new crew members were informed of the precautions required when working on deck while the gantry cranes were in operation.
Who it affects: All ship owners, operators and seafarers
Issue owner: Gearbulk Norway
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 16 Jun 2014
Status: Adequately addressed
Issue, description, who it affects
Issue: MO-2013-010-SI-03Emergency response
Number: MO-2013-010-SI-03
Description: MO-2013-010-SI-03:There was a lack of mapping information available to assist the ‘triple zero’ operator in providing the emergency responders with directions to a defined location within the port area.
Who it affects: Emergency service agencies
Issue owner: Port of Portland and the Emergency Services Telecommunications Authority
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 16 Jun 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-04Training
Number: RO-2013-014-SI-04
Description: RO-2013-014-SI-04:The training provided to the West Coast Wilderness Railway road-rail vehicle operators did not identify and incorporate local specific training requirements, such as operating on very steep grades and the use of radios.
Who it affects: All owners and operators of road-rail vehicles
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Rolling stock
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-05Radio communications
Number: RO-2013-014-SI-05
Description: RO-2013-014-SI-05:Rinadeena Station was the only emergency meeting point between Queenstown and Strahan and the only road access point on the rack between Halls Creek and Dubbil Barril. However, the Rinadeena Station radio was not maintained in a serviceable state at all times.
Who it affects: All track managers
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Operations control
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-08Radio procedures and protocols
Number: RO-2013-014-SI-08
Description: RO-2013-014-SI-08:The West Coast Wilderness Railway did not have documented radio communication procedures and their staff were not trained in the use of radios. As a result, radio protocols were not formalised and communications were ad hoc and casual in nature.
Who it affects: All track managers
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Operations control
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-06Hirail 3 testing and acceptance
Number: RO-2013-014-SI-06
Description: RO-2013-014-SI-06:West Coast Wilderness Railway had not developed and implemented a specification for the design, fitment and safety performance of road-rail vehicle rail guidance equipment.
Who it affects: All owners and operators of road-rail vehicles
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Rolling stock
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-014-SI-07Documented process for the testing of RRV’s
Number: RO-2013-014-SI-07
Description: RO-2013-014-SI-07:The West Coast Wilderness Railway did not have a documented process of testing road-rail vehicles.
Who it affects: All owners and operators of road-rail vehicles
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Rolling stock
Date, status, type
Date: 11 Jun 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-009-SI-01Supervision of trainee drivers
Number: RO-2012-009-SI-01
Description: RO-2012-009-SI-01:The Genesee and Wyoming Australia safety management system procedures did not provide supervising and trainee drivers with sufficient guidance or direction as to the extent of their supervisory or permitted driving roles.
Who it affects: All rolling stock operators
Issue owner: Genesee and Wyoming Australia
Operation affected: Rail: Freight
Date, status, type
Date: 28 May 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-003-SI-01Safety Management System
Number: MO-2013-003-SI-01
Description: MO-2013-003-SI-01:Calliope’s safety management system (SMS) did not provide the crew with adequate guidance regarding passage planning, training and familiarisation. Individual crew familiarisation records and risk assessment forms were not retained on board the yacht and there was no system of auditing or checking to ensure the adequacy of the SMS ...
Who it affects: All persons charged with navigating a vessel at sea
Issue owner: Marine Construction Management and the Cayman Islands Shipping Registry
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 12 May 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2013-003-SI-002Large yacht regulatory requirements
Number: MO-2013-003-SI-002
Description: MO-2013-003-SI-002:The Cayman Islands requirements in relation to a yacht’s compliance with the Large Commercial Yacht Code and other relevant legislation are determined by the yacht’s mode of operation. As a result, a commercially operated yacht in excess of 24 m in length must comply with the requirements of the Code ...
Who it affects: All persons charged with navigating a vessel at sea
Issue owner: Cayman Islands Shipping Registry
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 12 May 2014
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2013-003-SI-003Sydney Harbour pilotage requirements
Number: MO-2013-003-SI-003
Description: MO-2013-003-SI-003:Calliope was not required to carry a pilot during Sydney Harbour voyages because the yacht was considered to be a recreational vessel, even though the risks it posed to the port were the same as those posed by similarly sized commercially operated vessels.
Who it affects: All persons charged with navigating a vessel at sea
Issue owner: Sydney Ports Corporation
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 12 May 2014
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2013-007-SI-01Risk assessment
Number: MO-2013-007-SI-01
Description: MO-2013-007-SI-01:Atlantic Princess’s safety management system provided no guidance relating to actions that should be taken when persons less experienced than a pilot used a pilot ladder to board or disembark the ship.
Who it affects: All masters owners and operators of ships
Issue owner: Santoku Senpaku
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 May 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-007-SI-02Safe means of access
Number: MO-2013-007-SI-02
Description: MO-2013-007-SI-02:There were no facilities on board the Floating Offshore Transfer Barge Spencer Gulf that could be used to provide a safe means of access for personnel transfers between the barge and the ship. Furthermore, the barge operator’s procedures prohibited such personnel transfers.
Who it affects: Owners and operators of ports and offshore loading facilities
Issue owner: CSL Australia
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 May 2014
Status: Not addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2013-007-SI-03Safety management system compliance
Number: MO-2013-007-SI-03
Description: MO-2013-007-SI-03:The examples of non-compliance with the requirements of Whyalla Launch Services’ safety management system indicate that the system was not fully and effectively implemented on board Switcher.
Who it affects: All masters, owners and operators of ships and small vessels
Issue owner: Whyalla Launch Services
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 May 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-007-SI-05Safety management system guidance
Number: MO-2013-007-SI-05
Description: MO-2013-007-SI-05:Whyalla Launch Services’ safety management system did not provide effective guidance in relation to assessing a passenger’s ability to climb a pilot ladder or positioning of pilot launches while passengers were climbing and descending ladders. The system also referenced superseded SOLAS regulations and IMO resolutions relating to pilot ladders.
Who it affects: All masters owners and operators of ships and small vessels
Issue owner: Whyalla Launch Services
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 09 May 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: MO-2013-008-SI-01Visual and manual checking of ladder and manropes by pilots
Number: MO-2013-008-SI-01
Description: MO-2013-008-SI-01:The pilotage company’s procedures did not explicitly require the pilot to check the pilot ladder and manrope arrangements before disembarking the ship.
Who it affects: Pilotage companies
Issue owner: Australian Reef Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-008-SI-02Communication of readiness for pilot disembarkation
Number: MO-2013-008-SI-02
Description: MO-2013-008-SI-02:The pilotage company’s procedures for positive communication of readiness between the pilot and the launch crew were adequate. However, it was common for employees to vary these communication protocols, leaving perceptions of readiness open to error and misinterpretation.
Who it affects: Pilotage companies
Issue owner: Australian Reef Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-008-SI-03Use of a deck party to assist with the pilot transfer
Number: MO-2013-008-SI-03
Description: MO-2013-008-SI-03:The ship’s pilot transfer procedures did not specify a requirement for additional crew members to assist the supervising officer. As a result, the supervising officer was actively involved in deploying the pilot ladder and manropes, and transferring the pilot’s belongings to the launch, and could not focus his efforts on ...
Who it affects: Owners and operators of ships employing coastal pilots.
Issue owner: Dorval Ship Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-008-SI-04Communication of requirements for manropes
Number: MO-2013-008-SI-04
Description: MO-2013-008-SI-04:The pilotage company’s procedures did not require pilots to inform launch crews whether manropes would or would not be deployed in advance of the transfer.
Who it affects: Pilotage companies
Issue owner: Australian Reef Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2013-008-SI-05Securing of manropes to the deck
Number: MO-2013-008-SI-05
Description: MO-2013-008-SI-05:The ship’s pilot transfer procedures had not been revised to incorporate the most recent SOLAS requirements that manropes be secured at the rope end to a ring plate fixed to the deck.
Who it affects: Owners and operators of ships employing coastal pilots.
Issue owner: Dorval Ship Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 20 Mar 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: RO-2013-013-SI-01Independent data, an aid for understanding signalling occurrences
Number: RO-2013-013-SI-01
Description: RO-2013-013-SI-01:The ATSB investigation was unable to substantiate the reported observations of the train crew without having an independent source of data, such as forward facing video on train 5BM7.
Who it affects: All rail operators throughout Australia
Issue owner: Aurizon
Operation affected: Rail: Other
Date, status, type
Date: 05 Mar 2014
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2013-005-SI-01Condensate drainage pot design
Number: MO-2013-005-SI-01
Description: MO-2013-005-SI-01:The condensate drainage pots fitted to Nireas’ main air receivers were not fit for purpose as they were not capable of withstanding the internal pressures that were likely to accumulate in service.
Who it affects: Regulators, classification societies, masters, owners and operators of ships
Issue owner: Laskaridis Shipping / Jiangsu Jinling Shipyard / Lloyds Register / Australian Maritime Safety Authority
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 04 Mar 2014
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
  Proactive Action
  Proactive Action
  Safety Advisory Notice
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: RO-2013-024-S1-01Location of level crossing warning signage
Number: RO-2013-024-S1-01
Description: RO-2013-024-S1-01:On the southern approach to the level crossing, the Stop Sign Ahead (W3-1) warning sign was not located in accordance with the requirements of AS 1742.7-2007 standard.
Who it affects: Users of Pettavel Road level crossing
Issue owner: Surf Coast Shire Council
Operation affected: Rail: Other
Date, status, type
Date: 11 Feb 2014
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-023-SI-01Boundary fence
Number: RO-2013-023-SI-01
Description: RO-2013-023-SI-01:The boundary fence between the railway maintenance access track and Gallagher Road had been removed. As a result, over time and with regular use, the false perception that the maintenance access track was part of Gallagher Road was created and reinforced.
Who it affects: All local councils and track managers
Issue owner: The Australian Rail Track Corporation / Golden Plains Shire
Operation affected: Rail: Infrastructure
Date, status, type
Date: 05 Feb 2014
Status: Adequately addressed
Type: Proactive Action
  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: RO-2013-005-SI-01Management of risk associated with poor adhesion
Number: RO-2013-005-SI-01
Description: RO-2013-005-SI-01:Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion.  
Who it affects: All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-005-SI-03Assessment and recording of rail safety risks
Number: RO-2013-005-SI-03
Description: RO-2013-005-SI-03:Poor wheel/rail adhesion was not recognised as a risk in any of Queensland Rail’s risk registers and therefore this risk to the safety of rail operations was not being actively managed.
Who it affects: All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-005-SI-04Cross divisional recognition of rail safety risks
Number: RO-2013-005-SI-04
Description: RO-2013-005-SI-04:Despite numerous occurrences of slip-slide events in the years leading up to the accident at Cleveland, Queensland Rail’s risk management processes did not precipitate a broad, cross-divisional, consideration of solutions to the issue including an investigation of the factors relating to poor wheel/rail adhesion.
Who it affects: All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-05Application of safety actions from internal investigations
Number: RO-2013-005-SI-05
Description: RO-2013-005-SI-05:Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in precipitating appropriate safety action to the findings and recommendations of their investigations into the Beerwah SPADs in 2009 which identified wheel/rail adhesion issues.
Who it affects: All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-005-SI-07Awareness of rail safety occurrences in other jurisdictions affecting rail fleet type
Number: RO-2013-005-SI-07
Description: RO-2013-005-SI-07:Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in identifying safety issues pertinent to their fleet from rail safety occurrences in other jurisdictions involving poor wheel/rail adhesion.
Who it affects: All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-08Occurrence notification standard and guideline
Number: RO-2013-005-SI-08
Description: RO-2013-005-SI-08:The national rail occurrence standard and guidelines (ON-S1/OC-G1) do not include significant train wheel slip/slide occurrences as a notification category/type which has the potential to lead to rail safety regulators being unaware of significant and/or systemic safety issues related to wheel/rail adhesion.
Who it affects: Railway safety regulators and railway network owners and operators responsible for the classification and review of railway occurrence notifications.
Issue owner: The Office of the National Rail Safety Regulator
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-09Driver’s manual explanation of effects and control of low adhesion
Number: RO-2013-005-SI-09
Description: RO-2013-005-SI-09:The Queensland Rail driver’s manual did not explain the effects of low adhesion at the wheel/rail interface, how low adhesion is a precursor to prolonged wheel slide events and why these elements reduce the likelihood of achieving expected braking rates.
Who it affects: All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-10Effective coordination of emergency communications
Number: RO-2013-005-SI-10
Description: RO-2013-005-SI-10:The successful management of an emergency event from a remote location is critically dependent on clear and effective communication protocols. Communications within train control, and between train control and Cleveland station, were not sufficiently coordinated and resulted in misunderstandings at the Cleveland station accident site.
Who it affects: All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Operations control
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: RO-2013-005-SI-11Emergency management exercises
Number: RO-2013-005-SI-11
Description: RO-2013-005-SI-11:Emergency management simulation exercises to test the preparedness of network control staff, train crew, and station customer service staff to respond cooperatively to rail safety emergencies had not been undertaken in accordance with the Queensland Rail Emergency Management Plan.
Who it affects: All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-005-SI-12Post emergency debrief and findings
Number: RO-2013-005-SI-12
Description: RO-2013-005-SI-12:The Queensland Rail internal emergency debrief following the Cleveland station collision identified issues related to working with external agencies but did not address critical communication shortfalls within train control and between train control and the staff located at the Cleveland station accident site.
Who it affects: All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 20 Dec 2013
Status: Safety action pending
Type: Recommendation
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: RO-2013-005-SI-06Buffer stop design criterion
Number: RO-2013-005-SI-06
Description: RO-2013-005-SI-06:The mass of the two IMU or SMU class train units travelling on the Cleveland line was commonly heavier than the design specification of the buffer stop at Cleveland station. It is probable that Queensland Rail’s risk management systems did not consider this design criterion for these train configurations arriving ...
Who it affects: All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Issue owner: Queensland Rail Limited
Operation affected: Rail: Other
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-007-SI-01Pedestrian traffic light coordination
Number: RO-2012-007-SI-01
Description: RO-2012-007-SI-01:The Market Street pedestrian crossing traffic lights do not effectively coordinate with the level crossing equipment. When these lights are operating, vehicles can be forced to queue through the roundabout and thus block traffic that is attempting to exit the level crossing while a train is approaching.
Who it affects: All road and rail infrastructure managers
Issue owner: Wyndham City Council
Operation affected: Rail: Infrastructure
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2012-007-SI-02Level crossing length
Number: RO-2012-007-SI-02
Description: RO-2012-007-SI-02:The level crossing is longer than necessary. Shortening it would reduce the amount of time that a vehicle spends within the crossing and improve the visual information available to motorists when assessing their ability to clear the crossing.
Who it affects: All road and rail infrastructure managers
Issue owner: Metro Trains / Wyndham City Council
Operation affected: Rail: Infrastructure
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: RO-2012-007-SI-03Visual cues
Number: RO-2012-007-SI-03
Description: RO-2012-007-SI-03:Once within the level crossing there are no readily visible cues (like short range lights) to alert a driver that the level crossing protection system is operating.
Who it affects: All rail infrastructure managers
Issue owner: Metro Trains
Operation affected: Rail: Infrastructure
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: RO-2012-007-SI-04Escape or refuge areas
Number: RO-2012-007-SI-04
Description: RO-2012-007-SI-04:There is no available refuge or escape area within the traffic island at the northbound exit of the level crossing.
Who it affects: All road and rail infrastructure managers
Issue owner: Wyndham City Council
Operation affected: Rail: Infrastructure
Date, status, type
Date: 18 Dec 2013
Status: Adequately addressed
Type: Recommendation
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: MO-2012-006-SI-01Failure to keep a proper lookout
Number: MO-2012-006-SI-01
Description: MO-2012-006-SI-01:In the past 25 years the ATSB and its predecessor have investigated 39 collisions between trading ships and smaller vessels on the Australian coast. These investigations have all concluded that there was a failure of the watchkeepers on board one or both vessels to keep a proper lookout and that ...
Who it affects: Watchkeepers
Issue owner: Fukujin Kisen and all other operators
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 12 Dec 2013
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
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: RO-2013-003-SI-03Training for coach/tutor drivers
Number: RO-2013-003-SI-03
Description: RO-2013-003-SI-03:Pacific National Bulk Rail does not provide coach/tutor drivers with sufficient training and direction as to how to perform their role.
Who it affects: All rail operators
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 15 Nov 2013
Status: Adequately addressed
Issue, description, who it affects
Issue: RO-2013-003-SI-01Fatigue management system
Number: RO-2013-003-SI-01
Description: RO-2013-003-SI-01:Pacific National's fatigue management system is over-reliant on the use of a bio-mathematical model to predict individual fatigue risk, being based principally on rostered work hours without due consideration to higher level fatigue risk management strategies.
Who it affects: All rail operators
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 15 Nov 2013
Status: Adequately addressed
Issue, description, who it affects
Issue: RO-2013-003-SI-02Fatigue management training
Number: RO-2013-003-SI-02
Description: RO-2013-003-SI-02:Pacific National Bulk Rail division did not provide training on fatigue management to the driver.
Who it affects: All rail operators
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 15 Nov 2013
Status: Adequately addressed
Issue, description, who it affects
Issue: RO-2013-003-SI-04SPAD strategy
Number: RO-2013-003-SI-04
Description: RO-2013-003-SI-04:Pacific National’s SPAD strategy focuses on individual crew actions and the costs of SPADs, rather than developing integrated error tolerant systems of work with regard for the broader systemic issues known to contribute to SPAD events.
Who it affects: All rail operators
Issue owner: Pacific National
Operation affected: Rail: Freight
Date, status, type
Date: 15 Nov 2013
Status: Adequately addressed
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: RO-2013-011-SI-01Level crossing sighting
Number: RO-2013-011-SI-01
Description: RO-2013-011-SI-01:For approaches other than the one taken by this motor vehicle driver, this level crossing did not meet the requirements of Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings.
Who it affects: Users of Brown Street level crossing
Issue owner: Warrnambool City Council
Operation affected: Rail: Other
Date, status, type
Date: 29 Oct 2013
Status: Adequately addressed
Type: Safety Advisory Notice
Issue, description, who it affects
Issue: RO-2013-011-SI-02Level crossing signage
Number: RO-2013-011-SI-02
Description: RO-2013-011-SI-02:A review of the signage requirements for compliance with Australian Standard AS1742.7-2007, Manual of uniform traffic control devices, Part 7: Railway crossings indicated that the Stop Sign Ahead (W3-1) was missing on the northern side of the Brown Street level crossing.
Who it affects: Users of Brown Street level crossing
Issue owner: Warrnambool City Council
Operation affected: Rail: Other
Date, status, type
Date: 29 Oct 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: RO-2013-012-SI-01Twist defect detection
Number: RO-2013-012-SI-01
Description: RO-2013-012-SI-01:The twist defect was not detected by TasRail’s inspection/monitoring systems, increasing the risk of derailment.
Who it affects: TasRail
Issue owner: TasRail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-012-SI-02Elevated risk controls
Number: RO-2013-012-SI-02
Description: RO-2013-012-SI-02:TasRail had not instigated proactive action to manage the elevated risks associated with ongoing track stability issues at, or near, the derailment site in accordance with their maintenance procedures.
Who it affects: TasRail
Issue owner: TasRail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-012-SI-03Track inspection intervals
Number: RO-2013-012-SI-03
Description: RO-2013-012-SI-03:Track inspections were not consistently conducted at intervals of not more than 96 hours, in accordance with TasRail’s standard.
Who it affects: TasRail
Issue owner: TasRail
Operation affected: Rail: Infrastructure
Date, status, type
Date: 15 Oct 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2013-006-SI-01Management of special locations
Number: RO-2013-006-SI-01
Description: RO-2013-006-SI-01:The ARTC had not instigated proactive action to manage the increased risk of a buckling event in accordance with their procedure ETM-06-06 (Managing Track Stability – Concrete Sleepered Track) at section 1.11.5 - ‘Special Locations’.
Who it affects: All rail infrastructure managers
Issue owner: Australian Rail Track Corporation Limited
Operation affected: Rail: Infrastructure
Date, status, type
Date: 11 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: RO-2012-002-SI-01Response to significant weather events
Number: RO-2012-002-SI-01
Description: RO-2012-002-SI-01:The ARTC’s systems and operational procedures provided limited additional information or guidance to assist network control staff in identifying and assessing a potential threat to the serviceability of the infrastructure resulting from significant weather events.
Who it affects: All rail infrastructure managers
Issue owner: Australian Rail Track Corporation Limited
Operation affected: Rail: Infrastructure
Date, status, type
Date: 30 Aug 2013
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2012-005-SI-01On board planned maintenance system
Number: MO-2012-005-SI-01
Description: MO-2012-005-SI-01:The ship’s planned maintenance system did not include all of the main engine manufacturer’s maintenance requirements. Furthermore, the maintenance records did not include sufficient detail to confirm that the main engine was maintained in accordance with the manufacturer’s requirements.
Who it affects: Shipboard maintenance management
Issue owner: ID Wallem Ship Management
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 22 Aug 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2012-005-SI-02Class requirements
Number: MO-2012-005-SI-02
Description: MO-2012-005-SI-02:ClassNK did not have in place a system which ensured that updated service advice from the engine manufacturer was being implemented on board ships with engines which its surveyors were routinely and regularly surveying.
Who it affects: Ship and machinery inspection and survey, shipboard maintenance management
Issue owner: ClassNK (Nippon Kaiji Kyokai)
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 22 Aug 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: RO-2013-014-SI-01Risk assessment, procedure and guidelines
Number: RO-2013-014-SI-01
Description: RO-2013-014-SI-01:West Coast Wilderness Railway had not considered all of the risks associated with the operation of road-rail vehicles on the steep railway. As a result, documented operational procedures had not been developed and locations where vehicles could be safely on/off railed had not been defined.
Who it affects: All owners and operators of road rail vehicles
Issue owner: West Coast Wilderness Railway
Operation affected: Rail: Operations control
Date, status, type
Date: 15 Aug 2013
Status: Adequately addressed
Type: Proactive Action
  Recommendation
  Safety Advisory Notice
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: RO-2011-009-SI-01Wheel inspection processes
Number: RO-2011-009-SI-01
Description: RO-2011-009-SI-01:The wheel inspection processes prior to the failure of locomotive wheel L4 on SCT 008 were not effective in detecting surface damage or cracks
Who it affects: Rail Rolling stock owners, operators and maintainers
Issue owner: SCT Logistics
Operation affected: Rail: Freight
Date, status, type
Date: 03 Jul 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-009-SI-02Class BM Steel prone to subsurface Cracks
Number: RO-2011-009-SI-02
Description: RO-2011-009-SI-02:Subsurface cracks appeared to be more common on wheels made with Class BM grade steel while operating under conditions of high speed cyclic loading, such as the SCT class locomotives
Who it affects: Rail Rolling stock owners, operators and maintainers
Issue owner: SCT Logistics
Operation affected: Rail: Freight
Date, status, type
Date: 03 Jul 2013
Status: Adequately addressed
Type: Proactive Action
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: MO-2012-010-SI-03Stevedore working hours and fatigue
Number: MO-2012-010-SI-03
Description: MO-2012-010-SI-03:The stevedoring company had not identified stevedore fatigue as a risk to the company or its operations and, as a result, had not implemented a system to manage fatigue. Consequently, its operations were exposed to a level of fatigue-related risk that had not been assessed and treated.
Who it affects: All stevedoring companies and their employees
Issue owner: Newcastle Stevedores
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 04 Jun 2013
Status: Adequately addressed
Type: Recommendation
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2012-010-SI-02Aluminium ingot loading procedures
Number: MO-2012-010-SI-02
Description: MO-2012-010-SI-02:While the risk of aluminium ingot stacks toppling over had been identified by the stevedoring company as a result of past incidents, its procedure for loading aluminium products had not evolved to adequately address this risk. Furthermore, the implementation of basic precautions such as using ladders to climb between ingot ...
Who it affects: All stevedoring companies and their employees
Issue owner: Newcastle Stevedores
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 04 Jun 2013
Status: Adequately addressed
Type: Proactive Action
  Safety Advisory Notice
Issue, description, who it affects
Issue: MO-2012-010-SI-01Stability of aluminium ingot lifts
Number: MO-2012-010-SI-01
Description: MO-2012-010-SI-01:The aluminium ingot lifts in Newcastle, comprising multiple stacks of ingot packs strapped together, with an effective height to width ratio of 5:1 were inherently unstable. Furthermore, handling and stowage of ingot lifts involved the risk of a lift being disturbed and one or more of its packs falling or ...
Who it affects: Cargo handling companies and their employees
Issue owner: Patrick Ports and Stevedoring (Patrick) and Gearbulk Norway (Gearbulk)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 04 Jun 2013
Status: Partially addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: MO-2012-001-SI-03Risk assessment for the inner moorings
Number: MO-2012-001-SI-03
Description: MO-2012-001-SI-03:A risk assessment for mooring a ship at the inner moorings had never been undertaken. As a result, the risks associated with leaving a ship at the inner moorings overnight during the swell season were not properly identified and strategies to minimise those risks were not implemented.
Who it affects: Ships berthed at the inner moorings at Christmas Island
Issue owner: Patrick
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 23 May 2013
Status: Adequately addressed
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MO-2012-001-SI-04Guidance for masters of ships berthed at the inner moorings
Number: MO-2012-001-SI-04
Description: MO-2012-001-SI-04:While the pilot provided limited advice to masters of ships visiting Christmas Island, the port operator did not provide the master of ships intending to berth using the buoys in Flying Fish Cove with any written or verbal guidance regarding berthing and unberthing arrangements and emergency contingencies.
Who it affects: Ships berthed at the inner moorings at Christmas Island
Issue owner: Patrick
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 23 May 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2012-001-SI-02Joining shackle locking pin effectiveness
Number: MO-2012-001-SI-02
Description: MO-2012-001-SI-02:The port operator was aware that the type of locking pin arrangement on the cantilever line joining shackle was not effective in preventing the shackle’s pin from working its way free. However, the operator had not implemented a program of replacing the shackles in the entire mooring system in Flying ...
Who it affects: Ships berthed at the inner moorings at Christmas Island
Issue owner: Patrick
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 23 May 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2012-001-SI-01Inspection of the mooring system in Flying Fish Cove
Number: MO-2012-001-SI-01
Description: MO-2012-001-SI-01:The port operator had not implemented an effective planned inspection and maintenance program for the mooring system in Flying Fish Cove. Consequently, it had been 18 months since the underwater components of the cantilever line had been inspected.
Who it affects: Ships berthed at the inner moorings at Christmas Island
Issue owner: Patrick
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 23 May 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: RO-2012-003-SI-01Level crossing signage
Number: RO-2012-003-SI-01
Description: RO-2012-003-SI-01:There were some minor non-conformances with the level crossing signage, in particular the ‘Stop’ sign assembly and positioning of the ‘Stop’ line on the western side of the Port Flinders Causeway Road level crossing.
Who it affects: Rail infrastructure managers and maintence personel
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 19 Apr 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-012-SI-01XPT tail pin acceptance
Number: RO-2011-012-SI-01
Description: RO-2011-012-SI-01:RailCorp’s acceptance testing regime for tail pins did not identify that the tail pins stamped BU 06 04 were below standard and, hence, not suitable for service.
Who it affects: Operators of trains with this arrangement of tail pin
Issue owner: RailCorp
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 19 Apr 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-012-SI-02XPT tail pin testing
Number: RO-2011-012-SI-02
Description: RO-2011-012-SI-02:The method used to ultrasonically test the tail pins in-situ was not reliable and resulted in small fatigue cracks going undetected.
Who it affects: Operators of trains with this arrangement of tail pin
Issue owner: RailCorp
Operation affected: Rail: Passenger - regional
Date, status, type
Date: 19 Apr 2013
Status: Adequately addressed
Type: 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: RO-2011-016-SI-01Procedures for supervising drivers
Number: RO-2011-016-SI-01
Description: RO-2011-016-SI-01:Specialised Bulk Rail’s Safety Management System procedures did not provide the supervising drivers with sufficient direction as to the nature of their supervisory role.
Who it affects: All owners and operators of rollingstock
Issue owner: Specialized Bulk Rail (SBR)
Operation affected: Rail: Freight
Date, status, type
Date: 03 Apr 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-016-SI-02Information of the status of learning
Number: RO-2011-016-SI-02
Description: RO-2011-016-SI-02:There were no formalised processes for a driver-in-training to record their experience in learning a route, or to document feedback related to their performance, which could be used by supervising drivers or assessors to assist in mentoring them.
Who it affects: All owners and operators of rollingstock
Issue owner: Specialized Bulk Rail (SBR)
Operation affected: Rail: Freight
Date, status, type
Date: 03 Apr 2013
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-016-SI-03Procedures to attain route knowledge competency
Number: RO-2011-016-SI-03
Description: RO-2011-016-SI-03:Worker competency procedures were deficient in providing a structured program for the development of route knowledge by the driver-in-training.
Who it affects: All owners and operators of rollingstock
Issue owner: Specialized Bulk Rail (SBR)
Operation affected: Rail: Freight
Date, status, type
Date: 03 Apr 2013
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-016-SI-04Fatigue management controls
Number: RO-2011-016-SI-04
Description: RO-2011-016-SI-04:SBR’s process for assessing its drivers’ roster for relay operations relied excessively on a score produced by a bio-mathematical model, and it had limited mechanisms in place to ensure drivers received an adequate quantity and quality of sleep during relay operations.
Who it affects: All owners and operators of rollingstock
Issue owner: Specialized Bulk Rail (SBR)
Operation affected: Rail: Freight
Date, status, type
Date: 03 Apr 2013
Status: Partially 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: RO-2011-018-SI-01Authorisation of Control Signal Blocking
Number: RO-2011-018-SI-01
Description: RO-2011-018-SI-01:The rules and procedures governing the issue of a Controlled Signal Block did not require or provide for coordination between network control officers when the Controlled Signal Block affects more than one controller’s area of responsibility.
Who it affects: All track managers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Operations control
Date, status, type
Date: 27 Mar 2013
Status: Partially addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-01Bowen Tug and Barge safety management system adequacy
Number: MO-2011-011-SI-01
Description: MO-2011-011-SI-01:Bowen Tug and Barge’s safety management system guidance for barge storing operations did not designate roles or responsibilities to specific individuals and a system for communicating with the ship’s crew was not discussed and established.
Who it affects: All ship storing companies
Issue owner: Bowen Tug and Barge
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-02Bowen Tug and Barge compliance auditing
Number: MO-2011-011-SI-02
Description: MO-2011-011-SI-02:Bowen Tug and Barge did not have an effective compliance auditing process in place to ensure that its employees were following the training they had received and the guidance contained in the safety management system documentation.
Who it affects: Bowen Tug and Barge
Issue owner: Bowen Tug and Barge
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-03BP Shipping compliance auditing
Number: MO-2011-011-SI-03
Description: MO-2011-011-SI-03:Compliance auditing on board British Beech had not identified that requirements of the job hazard analysis were not being followed by the crew during the storing operations.
Who it affects: BP Shipping and all ship’s crew members
Issue owner: BP Shipping Ltd
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-04Bowen Tug and Barge incident reporting
Number: MO-2011-011-SI-04
Description: MO-2011-011-SI-04:The lack of any record of incident reporting by Bowen Tug and Barge, and its employees, indicates an ineffective reporting culture within the company. Hence, the opportunity to learn from previous incidents was lost.
Who it affects: Bowen Tug and Barge
Issue owner: Bowen Tug and Barge
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-011-SI-05Bowen Tug and Barge stores container handling
Number: MO-2011-011-SI-05
Description: MO-2011-011-SI-05:Bowen Tug and Barge had identified the need to spread the slings when lifting a stores container. However, there was no process in place to ensure that ships' crews were advised of this to ensure its safe return from the ship.
Who it affects: All ship’s stores handling organisations
Issue owner: Bowen Tug and Barge
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 07 Mar 2013
Status: Adequately addressed
Type: Proactive Action
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: MO-2011-005-SI-01SMS procedures for quick release of hook
Number: MO-2011-005-SI-01
Description: MO-2011-005-SI-01:Adonis’s safety management system did not contain any procedure or guidance in regard to the use and correct setting of the tug’s towing hook quick release arrangements.
Who it affects: All ship owners, operators and managers
Issue owner: Sea Swift, Cairns
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 08 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-005-SI-02Two tug requirement
Number: MO-2011-005-SI-02
Description: MO-2011-005-SI-02:The requirement in Sea Swift’s Marine Execution Plan to let Adonis go after clearing the Clinton coal wharves was ambiguous and this led to the crews of Adonis and Wolli misinterpreting the requirement.
Who it affects: All ship owners, operators and managers
Issue owner: Sea Swift, Cairns
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 08 Feb 2013
Status: Not addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-005-SI-03Towing hook locking pin positioning
Number: MO-2011-005-SI-03
Description: MO-2011-005-SI-03:The location of the towing hook ‘locking’ pin on the upper part of the quick release lever meant that if the pin was not properly in its ‘unlocked’ slot, it could fall into the locking hole, thereby locking the release lever.
Who it affects: All ship owners, operators and managers
Issue owner: Mampaey Offshore Industries, The Netherlands
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 08 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-010-SI-01Procedure for work over the side
Number: MO-2011-010-SI-01
Description: MO-2011-010-SI-01:MSC Siena’s safety management system procedure for working over the side required that a risk assessment be carried out, and necessary checks and precautions documented in a work permit. However, the procedure had not been effectively implemented on board the ship.
Who it affects: Allseas Marine ships’ crews
Issue owner: Allseas Marine, Greece
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Feb 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-010-SI-02Permit to work
Number: MO-2011-010-SI-02
Description: MO-2011-010-SI-02:MSC Siena’s permit to work over the side and the associated procedure required that the ship not be underway when working over the side. However, this requirement could not be complied with when working over the side to rig a combination pilot ladder.
Who it affects: Allseas Marine ships’ crews
Issue owner: Allseas Marine, Greece
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Feb 2013
Status: Adequately addressed
Type: 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: RO-2011-008-SI-01Assessment of Multiple Geometric Alignment Defects
Number: RO-2011-008-SI-01
Description: RO-2011-008-SI-01:The urgent and priority category defects detected by the AK Car on 4 February 2011 that were located within a 20 m track section were inadequately assessed and controlled in accordance with the ARTC Track and Civil Code of Practice.
Who it affects: Rail Infrastructure Owners and Maintainer
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 21 Jan 2013
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-008-SI-02Exceedence report fields
Number: RO-2011-008-SI-02
Description: RO-2011-008-SI-02:AK Car defect exceedence reports produced on 4 February 2011 did not include fields to record the date and time of follow-up field inspections and to show that these inspections and assessment of defects were completed in accordance with the ARTC Track and Civil Code of Practice.
Who it affects: Managers of Rail Infrastructure
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 21 Jan 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: MI-2010-011-SI-01Marine Orders Part 54
Number: MI-2010-011-SI-01
Description: MI-2010-011-SI-01:The safety framework prescribed by successive issues of Marine Orders Part 54 (MO 54) has not assigned the responsibility for the overall management of the safety risks associated with coastal pilotage operations to pilotage providers or any other organisation.
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Adequately addressed
Type: Recommendation
Issue, description, who it affects
Issue: MI-2010-011-SI-04Risk event and incident reporting
Number: MI-2010-011-SI-04
Description: MI-2010-011-SI-04:Risk identification and mitigation in coastal pilotage operations is inadequate as a result of the under-reporting of risk events and incidents by pilots.
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority, Australian Reef Pilots, Hydro Pilots and Torres Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Partially addressed
Type: Proactive Action
  Proactive Action
  Recommendation
  Proactive Action
  Recommendation
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MI-2010-011-SI-02Pilot training and professional development
Number: MI-2010-011-SI-02
Description: MI-2010-011-SI-02:The coastal pilot training program and ongoing professional development is inadequate.
Who it affects: All ship operators, masters, pilots and pilotage providers Safety
Issue owner: Australian Maritime Safety Authority
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: MI-2010-011-SI-03Pilot fatigue management plan
Number: MI-2010-011-SI-03
Description: MI-2010-011-SI-03:The coastal pilot fatigue management plan is inadequate.
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority, Australian Reef Pilots, Hydro Pilots and Torres Pilots
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Not addressed
Type: Recommendation
  Proactive Action
  Recommendation
  Proactive Action
  Recommendation
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: MI-2010-011-SI-05Check pilot system
Number: MI-2010-011-SI-05
Description: MI-2010-011-SI-05:As a measure to assess the adequacy of the individual systems of coastal pilotage and pilot competency, the check pilot system is ineffective.
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 24 Oct 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MI-2010-011-SI-06Great Barrier Reef and Torres Strait Vessel Traffic Service
Number: MI-2010-011-SI-06
Description: MI-2010-011-SI-06:The potential for the Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS) to support coastal pilotage and enhance safety is under-utilised. 
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority and Maritime Safety Queensland
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 24 Oct 2012
Status: Adequately addressed
Type: Proactive Action
  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: MO-2011-001-SI-01Port of Brisbane preparedness for incidents
Number: MO-2011-001-SI-01
Description: MO-2011-001-SI-01:Brisbane port authorities had not put in place sufficient procedures, checklists and/or supporting documents to ensure VTS staff were adequately prepared, trained and practiced to handle a predictable incident such as this.
Who it affects: MSQ Port of Brisbane
Issue owner: Maritime Safety Queensland (MSQ)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 05 Oct 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-001-SI-02Burner nozzle assembly and documentation
Number: MO-2011-001-SI-02
Description: MO-2011-001-SI-02:The design of the burner nozzle allowed the nozzle swirl plate and needle valve to be misaligned when being assembled which in turn led to the needle valve stem being damaged during assembly. Furthermore, the maintenance manuals and supporting documentation supplied by Garioni Naval, the thermal oil heater manufacturer, did ...
Who it affects: Garioni Naval SpA
Issue owner: Garioni Naval SpA
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 05 Oct 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-019-SI-01Policies, procedures and training
Number: RO-2011-019-SI-01
Description: RO-2011-019-SI-01:GWA policies, procedures and training had little if any guidance for employees quantifying the duration, consequential dangers and responses to severe weather events.
Who it affects: Rail infrastructure managers
Issue owner: Genesee & Wyoming Aust Pty Ltd (GWA)
Operation affected: Rail: Freight
Date, status, type
Date: 19 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2011-019-SI-02Monitoring of severe weather and flood events
Number: RO-2011-019-SI-02
Description: RO-2011-019-SI-02:The warning systems in place to alert GWA staff as to the severity of a flood event at the Edith River Rail Bridge were ineffective.
Who it affects: Rail infrastructure managers
Issue owner: Genesee & Wyoming Aust Pty Ltd (GWA)
Operation affected: Rail: Freight
Date, status, type
Date: 19 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-01Automatic defences within the ACIII system bypassed
Number: MO-2010-008-SI-01
Description: MO-2010-008-SI-01:When the main engine was operated in engine room control mode, there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’. As a result, the only system protections to warn the crew of ‘wrong ...
Who it affects: All ship's engineers
Issue owner: Newlead Bulkers
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-02Flinders Ports passage plan
Number: MO-2010-008-SI-02
Description: MO-2010-008-SI-02:While the Flinders Ports passage plan for Port Lincoln contained information relating to general navigation in the port, such as depths and navigation/channel marks, it did not contain actual passage specific information, such as courses and speeds to be followed. If the plan had contained course and speed information, the ...
Who it affects: All pilotage organisations
Issue owner: Flinders Ports
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-03Risk assessment and contingencies for manoeuvre
Number: MO-2010-008-SI-03
Description: MO-2010-008-SI-03:Flinders Ports had not undertaken a risk assessment, or developed contingency plans for this specific shiphandling manoeuvre in Port Lincoln. Consequently, the pilot had no guidance regarding what actions to take if the berthing manoeuvre did not progress as he planned.
Who it affects: All pilotage organisations
Issue owner: Flinders Ports
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-04Procedures for ACIII bridge control system
Number: MO-2010-008-SI-04
Description: MO-2010-008-SI-04:Newlead Bulkers had not implemented any procedures or guidance to inform the crew that extra vigilance was required when operating the main engine in engine room control mode because there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it ...
Who it affects: All ship owners, operators and managers
Issue owner: Newlead Bulkers
Operation affected: Marine: Shipboard operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2010-008-SI-05Tug masters participation
Number: MO-2010-008-SI-05
Description: MO-2010-008-SI-05:The participation of the two tug masters in the pilotage process was not actively encouraged in Port Lincoln. Consequently, it was not until after the collision that one of the tug masters advised the pilot that the ship's main engine was still running ahead.
Who it affects: All pilotage organisations
Issue owner: Flinders Ports
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 13 Sep 2012
Status: Adequately addressed
Type: Proactive Action
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: Trading ship operations in Gladstone
Description: The analysis of trading ship operations in Gladstone that had been carried out by the relevant authorities had not appropriately considered all that could be done to prevent the grounding of a ship as a result of steering gear or main engine failure. Action taken by Maritime Safety Queensland Maritime Safety Queensland ...
Who it affects: Maritime Safety Queensland
Issue owner:
Operation affected:
Date, status, type
Date: 30 Jul 2012
Original risk: Significant
Status:
Type: Recommendation
Issue, description, who it affects
Issue: MO-2011-004-SI-01Commissioning processes
Number: MO-2011-004-SI-01
Description: MO-2011-004-SI-01:The shipyard commissioning processes did not identify that the ship’s rudder angle indicator transmitter and tiller link-arm were not installed correctly.
Who it affects: All ship owners, operators, managers, masters and officers
Issue owner: Tsuneishi Group Shipbuilding, China
Operation affected: Marine: Other
Date, status, type
Date: 30 Jul 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: MO-2011-004-SI-02Contingency planning
Number: MO-2011-004-SI-02
Description: MO-2011-004-SI-02:There has not been a comprehensive risk based approach to contingency planning for deep draught bulk carrier operations in Gladstone.
Who it affects: All pilotage organisations
Issue owner: Maritime Safety Queensland (MSQ)
Operation affected: Marine: Other
Date, status, type
Date: 30 Jul 2012
Status: Partially addressed
Type: Recommendation
Issue, description, who it affects
Issue: MO-2011-004-SI-03Pilotage safety management system
Number: MO-2011-004-SI-03
Description: MO-2011-004-SI-03:There has not been a comprehensive safety management system implemented in the Port of Gladstone with the aim of identifying, evaluating and controlling pilotage related risk.
Who it affects: All pilotage organisations
Issue owner: Maritime Safety Queensland (MSQ)
Operation affected: Marine: Shore-based operations
Date, status, type
Date: 30 Jul 2012
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2010-015-SI-01Documentation and quality control
Number: RO-2010-015-SI-01
Description: RO-2010-015-SI-01:The quality assurance processes used in the acceptance of the Goddards crossing loop project were not sufficiently robust to mitigate the risk of track construction inadequacies.
Who it affects: Rail infrastructure managers and track maintainers
Issue owner: Australian Rail Track Corporation
Operation affected: Rail: Infrastructure
Date, status, type
Date: 29 Jun 2012
Status: Adequately addressed
Type: Proactive Action
Issue, de