Date Issue Released
Issue number
Safety issue title
Horizontal stabiliser bung design considerations
Safety Issue Description

The design of the horizontal stabiliser bungs did not consider aspects that would ensure the identification of an installed bung, or the safe operation of the aircraft if the bungs were not removed prior to flight.

Issue Owner
Regional Express Pty Ltd
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
No procedure for storage and accountability
Safety Issue Description

There were no formal procedures for the storage and accountability of horizontal stabiliser bungs after they were removed from the aircraft.

Issue Owner
Regional Express Pty Ltd
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Aircraft lighting regulation
Safety Issue Description

Regulatory requirements did not ensure that aircraft lighting was adequate to conduct night vision imaging system winching operations safely.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operational in-flight risk assessment guidance
Safety Issue Description

Although the operator’s procedures for winching and night vision imaging system operations included the need to have adequate hover references and a method of recovery in the event of a night vision goggle failure, there was limited guidance to ensure these requirements were confirmed by the flight crew on‑site before commencing precision hover operations.

Issue Owner
TOLL
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
TOLL recency requirements
Safety Issue Description

Toll recency for night vision imaging system (NVIS) winching was insufficient to ensure that complex NVIS winching operations, such as in this occurrence, could be conducted safely.

Issue Owner
TOLL
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
External white lighting
Safety Issue Description

The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height.

Issue Owner
TOLL
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Inappropriate use of the visual approach in marginal weather
Safety Issue Description

The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions.

Issue Owner
Eastern Air Link
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Issue number
Safety issue title
Inappropriate use of the visual approach in marginal weather
Safety Issue Description

The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions.

Issue Owner
Eastern Air Link
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Normalised, unauthorised procedure
Safety Issue Description

The aircraft system to be used in the event of a main deck cargo smoke event on the operator’s B737 fleet was being routinely used by the operator’s engineering personnel in Darwin as a means to cool the flight deck. This practice had become normalised as a result of the perceived benefit of doing so, but there were insufficient risk controls in place to ensure that the aircraft would be returned to the correct configuration prior to departure.

Issue Owner
Airwork Flight Operations Limited
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
CAAP 92 Guidance
Safety Issue Description

Recommendations in CASA guidance CAAP 92-1(1) requiring obstacle clearance out to 900 m may lead to circumstances where ALAs meet these requirements however, aircraft are required to manoeuvre below a safe height or be unable to outclimb rising terrain after take-off more than 900 m past the runway end.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Sample operations manual
Safety Issue Description

The CASA sample operations manual used by the operator that allowed any aerodrome in the Enroute Supplement Australia to be used for flight training did not assure that these aerodromes were suitable for use.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Risk management
Safety Issue Description

Network Aviation did not include the threat of unforecast weather below landing minima in their controlled flight into terrain risk assessments. This increased the risk that controls required to manage this threat would not be developed, monitored, and reviewed at a management level.

Issue Owner
Network Aviation
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Diversion procedure
Safety Issue Description

Network Aviation did not provide their flight crew with a diversion decision-making procedure for the circumstances where their flights encountered unforecast weather below landing minima. This increased the risk that their flight crew would not anticipate and be adequately prepared for a diversion.

Issue Owner
Network Aviation
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Mitigations to CPC design limitation
Safety Issue Description

The mitigations introduced by Airbus to counter the design limitation associated with the A330 cabin pressure control systems were ineffective, because:

  • changes to the CAB PR EXCESS CAB ALT alert operational procedure did not ensure appropriate management of the fault
  • the service bulletin had very limited uptake in the A330/340 global fleet.

 

Issue Owner
Airbus
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Operator training
Safety Issue Description

The operator’s training system did not adequately cover the unique requirements of the CAB PR EXCESS CAB ALT alert procedure, increasing the risk of an incorrect or delayed application of the required procedure.

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
Crash-resistant fuel system
Safety Issue Description

The aircraft was not fitted nor required to be fitted with a crash-resistant fuel system under the current standards or those in place at the time of manufacture. As a result, post-impact fire presents a significant risk of fire-related injuries and fatalities to aircraft occupants.

Response by the United States Federal Aviation Administration

Issue Owner
United States Federal Aviation Administration
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
DEENA 7 Standard instrument departure had no positive separation assurance method
Safety Issue Description

The DEENA 7 standard instrument departure has no designed positive separation method, making it susceptible to loss of separation occurrences.

 

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
DEENA 7 Standard instrument departure had no positive separation assurance method
Safety Issue Description

The DEENA 7 standard instrument departure has no designed positive separation method, making it susceptible to loss of separation occurrences. 

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
SFIS surveillance coverage
Safety Issue Description

The surveillance flight information service (SFIS) had been implemented in an area with known surveillance coverage limitations, resulting in the SFIS controller having no displayed positional information for the Caravan until it reached an altitude of about 1,500 feet. Therefore, during the period of conflict between the Caravan and B737, the controller was solely reliant on radio communications for situation awareness, reducing their ability to provide appropriate traffic and avoidance advice.

Issue Owner
Airservices Australia
Transport Function
Aviation: Airspace management
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Undetected cracking resulted in failure
Safety Issue Description

Failure of the inboard programming roller cartridge was due to undetected fatigue cracking that occurred in an area that was not included in the detailed flap actuation system inspection.

Issue Owner
The Boeing Company
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation