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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2014-190-SI-08Operator’s hazard identification processes
Number: AO-2014-190-SI-08
Description: AO-2014-190-SI-08:Although the operator’s safety management processes were improving, its processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had ...
Who it affects: Operator’s flight crew and other operational personnel
Issue owner: Pel-Air Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-07Operator’s installation of new aircraft systems on VH-NGA
Number: AO-2014-190-SI-07
Description: AO-2014-190-SI-07:Although the operator installed an enhanced ground proximity warning system (EGPWS) and traffic alert and collision avoidance system (TCAS) on VH-NGA in August 2009, it did not provide relevant flight crew with formal training on using these systems, or incorporate relevant changes into the aircraft’s emergency procedures checklists.
Who it affects: Operator’s Westwind flight crew
Issue owner: Pel-Air Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-06Operator’s fatigue management
Number: AO-2014-190-SI-06
Description: AO-2014-190-SI-06:The operator’s application of its fatigue risk management system overemphasised the importance of scores obtained from a bio-mathematical model of fatigue (BMMF), and it did not have the appropriate expertise to understand the limitations and assumptions associated with the model. Overall, the operator did not have sufficient risk controls in ...
Who it affects: Operator’s Westwind flight crew
Issue owner: Pel-Air Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-05Operator’s crew resource management training
Number: AO-2014-190-SI-05
Description: AO-2014-190-SI-05:Although the operator provided its flight crew with basic awareness training in crew resource management (CRM), it was limited in nature and did not ensure flight crew were provided with sufficient case studies and practical experience in applying relevant CRM techniques.
Who it affects: Operator’s Westwind flight crew
Issue owner: Pel-Air Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-04Operator’s emergency procedures and cabin safety
Number: AO-2014-190-SI-04
Description: AO-2014-190-SI-04:The operator’s risk controls did not provide assurance that the occupants on an air ambulance aircraft would be able to effectively respond in the event of a ditching or similar emergency. Specific examples included: insufficient information provided during pre-flight demonstrations and the passenger safety brief card to demonstrate how to use ...
Who it affects: Operator’s Westwind flight crew and medical personnel on air ambulance flights.
Issue owner: Pel-Air Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-03Pre-flight risk assessments for air ambulance tasks
Number: AO-2014-190-SI-03
Description: AO-2014-190-SI-03:The operator and air ambulance provider did not have a structured process in place to conduct pre-flight risk assessments for air ambulance tasks, nor was there any regulatory requirement for such a process.
Who it affects: Operator’s Westwind flight crew
Issue owner: Pel-Air Aviation / CareFlight
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: No longer relevant
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-02Operator’s risk controls for in-flight fuel management
Number: AO-2014-190-SI-02
Description: AO-2014-190-SI-02:The operator’s risk controls did not provide assurance that the operator’s Westwind pilots would conduct adequate in-flight fuel management and related activities during flights to remote islands or isolated aerodromes. Limitations included: no formal guidance material about how to calculate a point of no return (PNR) for an off-track alternate aerodrome no ...
Who it affects: Operator’s Westwind flight crew
Issue owner: Pel-Air Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-01Operator’s risk controls for flight/fuel planning
Number: AO-2014-190-SI-01
Description: AO-2014-190-SI-01:The operator’s Westwind pilots generally used a conservative approach to fuel planning, and the operator placed no restrictions on the amount of fuel that pilots uploaded. However, the operator’s risk controls did not provide assurance that there would be sufficient fuel on board flights to remote islands or isolated aerodromes. ...
Who it affects: Operator’s Westwind flight crew
Issue owner: Pel-Air Aviation
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AE-2014-054-SI-02Aircraft tracking
Number: AE-2014-054-SI-02
Description: AE-2014-054-SI-02:While there has been significant enhancements in the tracking of commercial aircraft in recent years there are some limitations to the improvements. The ICAO mandated 15-minute position tracking interval for existing aircraft may not reduce a potential search area enough to ensure that survivors and wreckage are located within a ...
Who it affects: Aircraft operators, aircraft manufacturers, and aircraft equipment manufacturers
Issue owner: State regulators
Operation affected: Aviation: Air transport
Date, status, type
Date: 03 Oct 2017
Status: Safety action pending
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: AE-2014-054-SI-01Search and rescue information
Number: AE-2014-054-SI-01
Description: AE-2014-054-SI-01:There is relatively limited public and official information available about the process and outcomes of some searches. It is not an explicit part of the ICAO Annex 13 guidelines for inclusion in an accident investigation report. Similarly there is no Annex 12 requirement to publish or analyse search information. This ...
Who it affects: International Civil Aviation Organization
Issue owner: International Civil Aviation Organization
Operation affected: Aviation: Air transport
Date, status, type
Date: 03 Oct 2017
Status: Safety action pending
Type: Recommendation
  Recommendation
Issue, description, who it affects
Issue: AO-2014-053-SI-05 Classification of parachuting operations
Number: AO-2014-053-SI-05
Description: AO-2014-053-SI-05 :Classification of parachuting operations in the private category did not provide comparable risk controls to other similar aviation activities that involve the carriage of the general public for payment.
Who it affects: Australian parachuting industry
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: Safety action pending
Type: Proactive Action
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2014-053-SI-04 Restraint use in parachuting aircraft
Number: AO-2014-053-SI-04
Description: AO-2014-053-SI-04 :It was likely that the parachutists on the accident flight, as well as those that had participated in previous flights, were not secured to the single-point restraints that were fitted to VH-FRT. While research indicates that single-point restraints provide limited protection when compared to dual-point restraints, they do reduce the ...
Who it affects: Australian parachuting industry
Issue owner: Occurrence operator
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: No longer relevant
Type: Proactive Action
  Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: AO-2014-053-SI-03Dual-point restraints
Number: AO-2014-053-SI-03
Description: AO-2014-053-SI-03:Research has identified that rear‑facing occupants of parachuting aircraft have a higher chance of survival when secured by dual-point restraints, rather than the standard single-point restraints that were generally fitted to Australian parachuting aircraft.
Who it affects: Australian parachuting industry
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: Safety action pending
Type: Proactive Action
  Recommendation
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2014-053-SI-02Unapproved aircraft flight control modifications
Number: AO-2014-053-SI-02
Description: AO-2014-053-SI-02:Some Cessna 206 parachuting aircraft, including VH-FRT, had their flight control systems modified without an appropriate maintenance procedure or approval. That increased the risk of flight control obstruction.
Who it affects: Parachute jump operators
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-053-SI-01 Secondary seat stop modification not mandatory
Number: AO-2014-053-SI-01
Description: AO-2014-053-SI-01 :Despite being categorised as mandatory for the pilot’s seat by the aircraft manufacturer, a secondary seat stop modification designed to prevent uncommanded rearward pilot seat movement and potential loss of control was not fitted to VH-FRT, nor was it required to be under United States or Australian regulations.
Who it affects: Single engine Cessna aircraft operators
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: General aviation
Date, status, type
Date: 23 Jun 2017
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2016-003-SI-01 Air traffic facilities at Ballina/Byron Gateway Airport
Number: AO-2016-003-SI-01
Description: AO-2016-003-SI-01 :Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence ...
Who it affects: All aircraft operations that utilise Ballina/Byron Gateway Airport
Issue owner: Operator-Ballina/Byron Gateway Airport
Operation affected: Aviation: Air transport
Date, status, type
Date: 19 May 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-032-SI-02Consideration of transient elevator deflections from a pitch disconnect
Number: AO-2014-032-SI-02
Description: AO-2014-032-SI-02:The aircraft manufacturer did not account for the transient elevator deflections that occur as a result of the system flexibility and control column input during a pitch disconnect event at all speeds within the flight envelope. As such, there is no assurance that the aircraft has sufficient strength to withstand ...
Who it affects: All operators of ATR 42 and ATR 72 aircraft
Issue owner: ATR
Operation affected: Aviation: Air transport
Date, status, type
Date: 05 May 2017
Status: Safety action pending
Type: Recommendation
  Recommendation
  Recommendation
  Proactive Action
Issue, description, who it affects
Issue: AO-2017-032-SI-01GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Number: AO-2017-032-SI-01
Description: AO-2017-032-SI-01:The ATSB advises that those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3 should note the facts presented in this preliminary report with a view to addressing any risks ...
Who it affects: Those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Issue owner: Operators and maintainers of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3
Operation affected: Aviation: Air transport
Date, status, type
Date: 13 Apr 2017
Status: Safety action pending
Type: Safety Advisory Notice
  Proactive Action
Issue, description, who it affects
Issue: AO-2013-120-SI-01Emergency oxygen mask and smoke goggles training
Number: AO-2013-120-SI-01
Description: AO-2013-120-SI-01:At the time of the occurrence, the approved QantasLink training did not provide first officers with sufficient familiarity on the use of the oxygen mask and smoke goggles. This likely contributed to the crew's communication difficulties, including with air traffic control.
Who it affects: All QantasLink DHC-8-315 pilots
Issue owner: QantasLink
Operation affected: Aviation: Air transport
Date, status, type
Date: 07 Apr 2017
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-005-SI-01Absence of air traffic control procedures and tools for runway changes at Melbourne Airport
Number: AO-2016-005-SI-01
Description: AO-2016-005-SI-01:Airservices Australia did not provide procedures with associated local instructions to Melbourne air traffic controllers regarding how to coordinate runway changes at Melbourne Airport. Furthermore, an absence of system tools increased the risk of the controllers forgetting to coordinate those changes with the Essendon Aerodrome Controller.
Who it affects: Air traffic controllers at Melbourne and Essendon Airports
Issue owner: Airservices Australia
Operation affected: Aviation: Airspace management
Date, status, type
Date: 09 Mar 2017
Status: Adequately addressed
Type: Proactive Action
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