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Safety issues and actions
Issue, description, who it affects Date, status, type
Issue, description, who it affects
Issue: AO-2015-105-SI-02Autopilot advice, limitations cautions and warnings (written and audible)
Number: AO-2015-105-SI-02
Description: AO-2015-105-SI-02:The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.
Who it affects: Aircraft owners and operators of aircraft fitted with the Garmin G1000 avionics system and GFC700 autopilot.
Issue owner: Garmin
Operation affected: Aviation: General aviation
Date, status, type
Date: 17 Apr 2018
Status: Safety action pending
Type: Recommendation
Issue, description, who it affects
Issue: AO-2015-066-SI-01Elevated risk from non-precision approach with low-level circling and non-stabilised approach procedure
Number: AO-2015-066-SI-01
Description: AO-2015-066-SI-01:The operator commenced regular public transport operations into Kosrae with the only instrument approach available for use being an offset procedure based on a non-precision navigation aid. The risk associated with this type of approach was amplified due to the need to use a 'dive and drive' style technique instead ...
Who it affects: Nauru Airlines
Issue owner: Nauru Airlines
Operation affected: Aviation: Air transport
Date, status, type
Date: 16 Mar 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2016-157-SI-01Safety reporting culture and procedures
Number: AO-2016-157-SI-01
Description: AO-2016-157-SI-01:The operator's documented procedure for company personnel to report accidents and incidents was in itself not sufficient to ensure that occurrences that had affected, or had the potential to affect safety, were reported to management. This decreased the opportunity for the operator to identify potential operational risks and take appropriate ...
Who it affects: All owners and operators of aircraft
Issue owner: Rebel Ag Pty Ltd
Operation affected: Aviation: General aviation
Date, status, type
Date: 13 Mar 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: RO-2014-009-SI-04Processes for evacuating trains
Number: RO-2014-009-SI-04
Description: RO-2014-009-SI-04:Rules and procedures for detrainment do not consider a priority option of moving the train to a station or platform.
Who it affects: All rail operations
Issue owner: NSW Trains; Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 17 Jan 2018
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2014-009-SI-03Unclear purpose of communication
Number: RO-2014-009-SI-03
Description: RO-2014-009-SI-03:The purpose of communication between key operational people was not always clearly stated nor understood leading to misunderstandings between people.
Who it affects: All rail operations
Issue owner: NSW Trains; Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 17 Jan 2018
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2014-009-SI-02Management of change
Number: RO-2014-009-SI-02
Description: RO-2014-009-SI-02:Key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority.
Who it affects: All rail operations
Issue owner: NSW Trains; Sydney Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 17 Jan 2018
Status: Adequately addressed
Type: Proactive Action
  Proactive Action
Issue, description, who it affects
Issue: RO-2014-009-SI-01Train protection
Number: RO-2014-009-SI-01
Description: RO-2014-009-SI-01:The crew of V938 detrained passengers onto the track near Kilbride without having arranged the required train protection with the ARTC Network Controller in accordance with the ARTC Network rules and procedures.
Who it affects: All rail operations
Issue owner: NSW Trains
Operation affected: Rail: Passenger - metropolitan
Date, status, type
Date: 17 Jan 2018
Status: Adequately addressed
Type: Proactive Action
Issue, description, who it affects
Issue: AO-2014-190-SI-16Guidance information on the limitations of FAID
Number: AO-2014-190-SI-16
Description: AO-2014-190-SI-16:Guidance material associated with the FAID bio-mathematical model of fatigue did not provide information about the limitations of the model when applied to roster patterns involving minimal duty time or work in the previous 7 days.
Who it affects: All operators and flight crew: Air transport and general aviation
Issue owner: InterDynamics
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-15Regulatory surveillance – assessing process in practice
Number: AO-2014-190-SI-15
Description: AO-2014-190-SI-15:Consistent with widely-agreed safety science principles, the Civil Aviation Safety Authority’s approach to surveillance of larger charter operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the actual conduct of line operations (or ‘process in practice’).
Who it affects: All operators
Issue owner: Civil Aviation Safety Authority
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-14Regulatory surveillance – scoping of audits
Number: AO-2014-190-SI-14
Description: AO-2014-190-SI-14:The Civil Aviation Safety Authority’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.
Who it affects: All operators
Issue owner: Civil Aviation Safety Authority
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-13Regulatory surveillance – surveillance planning
Number: AO-2014-190-SI-13
Description: AO-2014-190-SI-13:Although the Civil Aviation Safety Authority (CASA) collected or had access to many types of information about a charter and/or aerial work operator, the information was not integrated to form a useful operations or safety profile of the operator. In addition, CASA’s processes for obtaining information on the nature and ...
Who it affects: All operators
Issue owner: Civil Aviation Safety Authority
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-12Classification of air ambulance operations
Number: AO-2014-190-SI-12
Description: AO-2014-190-SI-12:Although air ambulance flights involved transporting passengers, in Australia they were classified as ‘aerial work’ rather than ‘charter’. Consequently, they were subject to a lower level of regulatory requirements than other passenger-transport operations (including requirements for fuel planning flights to remote islands).
Who it affects: All operators and flight crew that conduct air ambulance operations
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status:
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2014-190-SI-11Regulatory requirements and guidance for in-flight fuel management
Number: AO-2014-190-SI-11
Description: AO-2014-190-SI-11:The available regulatory guidance on in-flight fuel management 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: All operators and flight crew, particularly those who conduct flights to remote or isolated aerodromes
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status:
Type: Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2014-190-SI-10Regulatory requirements and guidance for fuel planning of flights to remote islands and isolated aerodromes
Number: AO-2014-190-SI-10
Description: AO-2014-190-SI-10:Although passenger-carrying charter flights to Australian remote islands were required to carry alternate fuel, there were no explicit fuel planning requirements for other types of other passenger-carrying flights to remote islands. There were also no explicit Australian regulatory requirements for fuel planning of flights to isolated aerodromes. In addition, Australia ...
Who it affects: All operators and flight crew who conduct flights to remote or isolated aerodromes
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Air transport
Date, status, type
Date: 23 Nov 2017
Status:
Type: Proactive Action
  Proactive Action
  Recommendation
Issue, description, who it affects
Issue: AO-2014-190-SI-09Operator’s roles and responsibilities of key personnel
Number: AO-2014-190-SI-09
Description: AO-2014-190-SI-09:The operator had not formally defined the roles and responsibilities of key positions involved in monitoring and managing flight operations, such as the standards manager for each fleet and the General Manager Flying Operations (Medivac and Charter).
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-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
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