Date Issue Released
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
Issue number
Safety issue title
National Jet Systems cabin air quality event procedures
Safety Issue Description

National Jet Systems’ cabin air quality events procedure focused on the recording/reporting of odours, post-flight care of crew and maintenance actions. However, it did not consider the possible application of the smoke/fumes procedure, or incapacitation procedure. As a result, there was an increased risk of flight crew being adversely affected by such an event during a critical stage of flight.

Issue Owner
National Jet Systems
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator risk management
Safety Issue Description

The operator's hazard and risk register, which formed part of the organisation's safety management system, did not identify inadvertent entry into instrument meteorological conditions as a hazard, which reduced the ability of the organisation to effectively manage the related risk.

Issue Owner
Executive Helicopters
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
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