Date Issue Released
Issue number
Safety issue title
Flight and ground crew knowledge of ground signals
Safety Issue Description

Regional Express did not provide flight crew or ground crew recurrent training to review the hand signals required to communicate with each other, including those used in an emergency.

Issue Owner
Regional Express
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
No formal company training
Safety Issue Description

Rex did not ensure its flight crews received training in the differences between passenger and freight‑configured Saab 340 aircraft, prior to being scheduled to fly freight operations.

Issue Owner
Regional Express Airlines
Transport Function
Aviation: Air transport
Date issue released
Issue Status
No longer relevant
Mode of Transport
Aviation
Issue number
Safety issue title
Operator documentation and crew familiarity
Safety Issue Description

The Pel-Air and Rex Saab 340 flight crew operating manuals did not include reference to the location and operation of the cross-valve handle or smoke curtain.

Issue Owner
Pel-Air Aviation and Regional Express Airlines
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Saab documentation for cargo configured aircraft
Safety Issue Description

Saab did not include the smoke curtain fitment in pre-flight documentation for the cargo‑configured Saab 340 aircraft to inform flight crew of this difference from the passenger‑configured version.

Issue Owner
Saab
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
National Large Air Tanker standard operating procedures
Safety Issue Description

Australian states and territories that engage in Large Air Tanker (LAT) operations have developed their own separate standard operating procedures (SOPs) for LATs and aerial supervision assets. This can result in safety requirements being omitted or misunderstood by the different tasking agencies, such as a minimum drop height, resulting in inconsistencies in the development and application of LAT SOPs.

Issue Owner
Australasian Fire and Emergency Services Authorities Council through the National Aerial Firefighting Centre Strategic Committee
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Crew resource management practice
Safety Issue Description

The Coulson Aviation crew resource management practice of limiting the pilot monitoring (PM) announcements to deviations outside the target retardant drop parameter tolerances increased the risk of the aircraft entering an unrecoverable state before the PM would alert the pilot flying.

ATSB comment

Coulson Aviation have not advised the ATSB of any safety action taken to address this safety issue and therefore the ATSB issues the following safety recommendation.

Issue Owner
Coulson Aviation
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Inadequate procedural requirements
Safety Issue Description

Coulson Aviation and the relevant Western Australian Government Departments had not published a minimum retardant drop height in their respective operating procedures for large airtankers. Consequently, the co-pilot (pilot monitoring), who did not believe there was a minimum drop height, did not alert the aircraft captain (pilot flying) to a drop height deviation prior to the collision.

Issue Owner
Western Australian Department of Fire and Emergency Services, and Department of Biodiversity, Conservation and Attractions
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Inadequate procedural requirements
Safety Issue Description

Coulson Aviation and the relevant Western Australian Government Departments had not published a minimum retardant drop height in their respective operating procedures for large airtankers. Consequently, the co-pilot (pilot monitoring), who did not believe there was a minimum drop height, did not alert the aircraft captain (pilot flying) to a drop height deviation prior to the collision.

Issue Owner
Coulson Aviation
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Drop speed recalculation
Safety Issue Description

The Coulson Aviation practice of recalculating the target retardant drop airspeed after a partial drop reduced the post-drop stall speed and energy‑height safety margins.

Issue Owner
Coulson Aviation
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Fatigue risk management system
Safety Issue Description

Likely due to an underlying lack of resources within Airservices Australia, there was an over‑reliance on tactical changes to manage the roster. As a result, cumulative fatigue was not being effectively managed strategically and an over‑reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.

Issue Owner
Airservices Australia
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Fatigue assessment of low workload
Safety Issue Description

Although Airservices Australia’s fatigue assessment and control tool (FACT) had the means of identifying situational factors that influenced fatigue, it had limited effectiveness as supervisors were not identifying low workload as a fatigue hazard. 

Issue Owner
Airservices Australia
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Fatigue risk management system
Safety Issue Description

Likely due to an underlying lack of resources within Airservices Australia, there was an over‑reliance on tactical changes to manage the roster. As a result, cumulative fatigue was not being effectively managed strategically and an over‑reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.

Issue Owner
Airservices Australia
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s procedure to use mixture to simulate engine failure
Safety Issue Description

Fly Oz's asymmetric training procedure involved failing one engine using the mixture control without confirmation the engine was subsequently restarted, rather than reducing throttle to simulate zero thrust in accordance with the Beechcraft E55 Airplane Flight Manual. This increased the risk of undetected asymmetric operation during descent and landing and the associated loss of control.

Issue Owner
Fly Oz
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Threshold visibility
Safety Issue Description

Due to topography and buildings at Mildura Airport, aircraft are not directly visible to each other on the threshold of runway 09, 27 and 36. The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.

Issue Owner
Mildura Airport
Transport Function
Aviation: Airports
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Swissport training and audits
Safety Issue Description

Swissport did not ensure that the implemented training and audits for Link Airways Saab 340B dispatches incorporated all of the elements required in its Ground operations manual for pre‑departure walk-arounds.

Issue Owner
Swissport
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Link training guidance lacked details regarding propeller straps
Safety Issue Description

Guidance provided by Link Airways for training of Swissport dispatch coordinators did not explain the appearance, function and importance of the propeller straps.

Issue Owner
Link Airways
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Propeller strap deterioration
Safety Issue Description

The propeller strap did not have a high-visibility streamer attached, and Link Airways did not effectively manage the condition of propeller straps for its Saab 340B fleet. This affected the visibility of the straps during ground operations.

Issue Owner
Link Airways
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Strap extension not always fitted
Safety Issue Description

On one-third of the Link Airways Saab 340B flights for which video surveillance was examined, including the occurrence flight, the flight crews did not fit the strap extension between the propeller strap and the airstairs. As the cabin door could not be closed with the strap extension in place, its correct fitment would almost certainly prevent a flight from proceeding with a propeller strap fitted.

Issue Owner
Link Airways
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Helicopter operations checklist
Safety Issue Description

An earlier version of the helicopter operations checklist was used by the crew of the Tai Keystone. That checklist did not include a requirement, present in the version current at the time of the incident, to remove handrails or stanchions from the helicopter landing site. 

Issue Owner
Taiwan Navigation Co Ltd
Transport Function
Marine: Shipboard operations
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Marine
Issue number
Safety issue title
National Jet Systems pilot incapacitation training
Safety Issue Description

Although National Jet Systems contained procedures for recognition and management of pilot incapacitation, the associated training did not include the identification and response to subtle physical or cognitive incapacitation.

Issue Owner
National Jet Systems
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation