Date:
Issue number
Safety issue title
Critical item
Safety Issue Description

Although the helicopter manufacturer’s instructions for continuation in service for the clutch shaft forward yoke specified that the condition of the yoke was to be inspected to verify that no cracks, corrosion, or fretting was present, it did not provide specific instructions for the method to be employed. The visual inspection that was employed increased the risk that a crack in that area may not be detected.

Issue Owner
Robinson Helicopter Company
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Pre-flight risk assessment tool
Safety Issue Description

Coulson Aviation did not provide a pre-flight risk assessment for their fire-fighting large air tanker crews. This would provide predefined criteria to ensure consistent and objective decision-making with accepting or rejecting tasks, including factors relating to crew, environment, aircraft and external pressures.

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
Windshear warning systems
Safety Issue Description

Coulson Aviation fleet of C-130 aircraft were not fitted with a windshear detection system, which increased the risk of a windshear encounter and/or delayed response to a windshear encounter during low level operations.

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
Windshear procedures and training
Safety Issue Description

Coulson Aviation did not include a windshear recovery procedure or scenario in their C‑130 Airplane Flight Manual and annual simulator training respectively, to ensure that crews consistently and correctly responded to a windshear encounter with minimal delay.

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
Coulson Aviation’s risk management processes
Safety Issue Description

Coulson Aviation's safety risk management processes did not adequately manage the risks associated with large air tanker operations. There were no operational risk assessments conducted or a risk register maintained. Further, as safety incident reports submitted were mainly related to maintenance issues, operational risks were less likely to be considered or monitored. Overall, this limited their ability to identify and implement mitigations to manage the risks associated with their aerial firefighting operations.

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
Initial attack certification
Safety Issue Description

The New South Wales Rural Fire Service procedures allowed operators to determine when pilots were initial attack capable. However, they intended for the pilot in command to be certified by the United States Department of Agriculture Forest Service certification process.

Issue Owner
New South Wales Rural Fire Service
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Rural Fire Service aerial supervision requirements
Safety Issue Description

The New South Wales Rural Fire Service had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision.

Issue Owner
New South Wales Rural Fire Service
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Rural Fire Service task rejection management
Safety Issue Description

The New South Wales Rural Fire Service did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation.

Issue Owner
New South Wales Rural Fire Service
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Passenger brace positions
Safety Issue Description

The maximum number of passengers that the balloon operator allowed to be carried meant that there was insufficient room in the basket for them to adopt the landing position specified in the operator's procedures to reduce the risk of injury.

Issue Owner
Picture This Ballooning
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Procedure for a rapid disembarkation
Safety Issue Description

Qantas did not have a procedure for a rapid disembarkation, or other similar procedure that would effectively enable rapid deplaning at a slower and more controlled pace than an emergency evacuation. Therefore, the only option for rapid deplaning was an emergency evacuation utilising slides, which unnecessarily increased the risk of injuries in some situations.

Issue Owner
Qantas Airways Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Cabin crew training
Safety Issue Description

Qantas's cabin crew recurrent training did not include any situation whereby a disarmed door would have to be rearmed in an emergency. This increased the likelihood that a door would be opened without the escape slide deployed, reducing the number of available exits.

Issue Owner
Qantas Airways Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Evacuation commands
Safety Issue Description

Qantas's cabin crew primary evacuation commands did not include phrases such as 'leave everything behind' and 'jump and slide'; instead, these phrases were optional. Consequently, passengers would generally not receive specific guidance until they reached an exit, which would likely slow down the evacuation.

Issue Owner
Qantas Airways Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Passenger safety information
Safety Issue Description

Qantas’s method of briefing passengers provided limited and inconsistent information about how to use the escape slides safely and what to do with cabin baggage in an emergency.

Issue Owner
Qantas Airways Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Risk controls associated with pilots identifying fatigue risks associated with insufficient sleep and extended wakefulness
Safety Issue Description

The sleep log tool used by the operator contained a coding error and it also pre-loaded sleep periods of future nights by default. This combination of factors reduced the likelihood pilots would identify fatigue risks associated with insufficient sleep and extended wakefulness.

Issue Owner
Heli-Aust Whitsundays Pty Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Use of sleep reporting spreadsheet and potential for modification of data input to meet operator’s minimum requirements
Safety Issue Description

The operator's fatigue risk management system relied extensively on a sleep reporting spreadsheet (sleep log) that was based on the prior sleep wake model, and the spreadsheet had a transparent rule set that made the recorded data easy to modify to achieve results that met the operator’s minimum sleep and wake requirements.

Issue Owner
Heli-Aust Whitsundays Pty Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s circuit and approach procedures for marine pilot transfer operations and criteria for achieving a stabilised approach
Safety Issue Description

The operator’s circuit and approach procedures for marine pilot transfer operations did not minimise pilot workload or provide the recommended stabilised approach criteria with mandatory go-around policy. These procedures could allow a combination of conditions that increased the risk of a sustained abnormal flight path and collision with terrain/water.

Issue Owner
Heli-Aust Whitsundays Pty Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s training and assessing procedures for marine pilot transfer operations in degraded visual cueing environments
Safety Issue Description

The operator's training and assessing procedures for marine pilot transfer operations did not provide assurance that pilot under supervision experience, helicopter instrumentation, and instructor capability were suitable for line training at night in a degraded visual cueing environment.

Issue Owner
Heli-Aust Whitsundays Pty Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Configuration of instrument panel for instructor or training/check pilot in degraded visual cueing environments
Safety Issue Description

The instrument panels fitted to VH-ZGA and the operator's other EC135 helicopter at Port Hedland were equipped for single-pilot operation under the instrument flight rules. When used for flight training or checking in a degraded visual cueing environment, this configuration has a detrimental effect on the ability of an instructor or training/check pilot to monitor the helicopter's flight path and take over control if required.

Issue Owner
Heli-Aust Whitsundays Pty Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Organisational change
Safety Issue Description

Changes in the operator's key safety post holder positions, safety reporting systems and internal processes reduced effective safety assurance.

Issue Owner
Alliance Airlines Pty Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Flight crew training
Safety Issue Description

The operator’s training for the Fokker F28-Mk0100 did not prepare pilots for alpha mode activation during critical phases of flight.

Issue Owner
Alliance Airlines Pty Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation