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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-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 safety demonstrations and the passenger safety brief card to demonstrate how to ...
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 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 policies, procedures, training and guidance 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 ...
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: 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
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