Date Issue Released
Issue number
Issue Owner
Damoda Intelligent Control Techology Co., Ltd
Safety issue title
Aircraft control software
Safety Issue Description

Version 3 of the Damoda ground control station software included a wind speed readout, but did not actively alert the pilot if the wind speed limit was exceeded. This increased the risk that a pilot would fail to identify a limit exceedance and continue a show into unsafe conditions.

Response By Damoda Intelligent Control Technology Co., Ltd

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
The Australian Traffic Network Pty Limited
Safety issue title
Ground Control Station pilot assurance
Safety Issue Description

The operator did not provide formal training on version 3 of the ground control station software to its pilots. Instead, relying on familiarisation flights and ad hoc advice from the manufacturer. This increased the risk that show-qualified pilots would fail to identify exceedances in flight critical parameters and experience increased workload.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
The Australian Traffic Network Pty Limited
Safety issue title
No trigger in key operational documents to use weather drone
Safety Issue Description

Following the introduction of a weather drone option to the wind management plan in June of 2023, the operator had not updated its operational procedures to include this option. As a result, flight crew were not prompted to use this method for gathering information on wind conditions in the show area prior to launch.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
MAGSPEC Aviation Pty Ltd
Safety issue title
Risk management framework
Safety Issue Description

MAGSPEC Aviation's safety risk management processes did not include a pre‑operational risk assessment that recognised the generic risks and hazards common across that type of operation nor was a risk register maintained. Consequently, there was limited assurance that all the risks had been identified and that all reasonable mitigations had been applied.

Response by MAGSPEC Aviation Pty Ltd

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Fly Esperance Pty Ltd
Safety issue title
Cessna 206 emergency exit modifications
Safety Issue Description

The aircraft did not have the modifications recommended by CASA for Cessna 206 emergency exits, increasing the likelihood of impeded egress during emergency situations.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Robinson Helicopter Company
Safety issue title
Asymmetric stabiliser contribution to uncommanded right roll
Safety Issue Description

The asymmetric horizontal stabiliser design in the Robinson R22, R44 and R66 models significantly contributed to the uncommanded right roll rate during low‑G conditions and the risk of an in‑flight break‑up. 

Response by Robinson Helicopter Company

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Robinson Helicopter Company
Safety issue title
Pilot’s operating handbook
Safety Issue Description

The Robinson Helicopter pilot’s operating handbook sections for operation in high winds or turbulence did not warn of the potential for turbulence-induced low‑G, and rapid right roll, particularly at high airspeed or provide guidance for appropriate control inputs in response to a turbulence-induced low‑G situation. This increased the risk of pilots encountering low‑G independent of control inputs, and an in‑flight break‑up. 

Response by Robinson Helicopter Company

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Fly Esperance Pty Ltd
Safety issue title
The operator’s pre-flight passenger briefing
Safety Issue Description

The operator’s pre-flight passenger briefing did not include the demonstration of, and pilots were not trained how to operate, the emergency exit via the cargo door with the flaps extended.

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

The Civil Aviation Safety Regulations Part 139 (Aerodromes) Manual of Standards 2019 section relating to the temporary closure of a taxiway at night did not:

  • provide a recommendation that when operating on an aerodrome with significant obscuring background lighting, consideration be given to increasing the span of unserviceability lights, similar to the recommendation provided for markers to cross the entire closed area
  • specify that both markers and unserviceability lights were required.
Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Airports
Issue number
Issue Owner
AGAIR
Safety issue title
Normalisation of deviance
Safety Issue Description

The AGAIR aircraft VH-HPY pressurisation system could not reliably attain the required cabin altitude during flight due to a known, long-term, unresolved intermittent defect. AGAIR management personnel were aware of the defect and, through a combination of inaction, encouragement and, in some instances direct involvement, permitted the aircraft to continue operations at an excessive cabin altitude.

Issue Status
No longer relevant
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Airservices Australia
Safety issue title
Air traffic control hypoxia emergency procedures
Safety Issue Description

The Airservices Australia hypoxic pilot emergency checklist did not contain guidance on ceasing the emergency response. This increased the risk that a controller may inappropriately downgrade the emergency response during a developing hypoxic scenario. 

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
AGAIR
Safety issue title
Aircraft defects not recorded
Safety Issue Description

AGAIR Gulfstream 690 and 695 aircraft were operated with known defects without being recorded on the aircrafts’ maintenance release, likely as a routine practice. For VH-HPY, the absence of documented historical information limited the ability to assess the operational impact of the pressurisation defect and the effectiveness of maintenance rectification activities. 

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
AGAIR
Safety issue title
Operational control
Safety Issue Description

AGAIR management exercised ineffective operational control over the line scanning activities. As a result, the ongoing intermittent pressurisation defect was not formally recorded, the issues with the aircraft were not communicated to the AGAIR safety manager, and the hazardous practice of operating the aircraft at a cabin altitude that required the use of supplemental oxygen, without access to a suitable oxygen supply, was allowed to continue.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Batik Air
Safety issue title
Batik Air change management process
Safety Issue Description

Batik Air's change management processes were not effective at fully identifying and mitigating the risks associated with the commencement of the Denpasar to Canberra route.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Batik Air
Safety issue title
Batik Air common traffic advisory frequency training
Safety Issue Description

Batik Air did not ensure that flight crew completed all common traffic advisory frequency (CTAF) training prior to them operating flights into Australia where the use of these procedures could be required.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Civil Aviation Safety Authority
Safety issue title
Guidance on intersecting runways at non controlled aerodromes
Safety Issue Description

The Civil Aviation Safety Authority guidance for pilots using non-controlled aerodromes did not clearly define the active runway. The guidance did not provide practical advice to pilots using a secondary runway, and in some situations, it was contrary to existing regulations.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Caboolture Gliding Club Inc
Safety issue title
Gliding club's use of runway 06
Safety Issue Description

The Caboolture Gliding Club had a regular practice of using runway 06 for some flights, including during periods of light traffic on runway 11/29. This increased the risk of collision as Caboolture was a non-controlled aerodrome relying on alerted see-and-avoid principles, and there was a stand of trees obstructing pilots' vision of intersecting runways.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Caboolture Aero Club
Safety issue title
Caboolture Airfield visibility hazards
Safety Issue Description

The Caboolture Aero Club did not effectively manage or inform pilots of the risk presented by trees and buildings around the airfield that prevented pilots from being able to see aircraft on intersecting runways and approach paths.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Airports
Issue number
Issue Owner
De Havilland Aircraft of Canada Limited
Safety issue title
Dash 8 operator guidance
Safety Issue Description

De Havilland Aircraft of Canada Limited did not publish any guidance to operators of Dash 8 aircraft on the transmission and reception performance limitations of VHF COM 2 radios for ground-based communications.

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

The QantasLink radio procedure required Dash 8 flight crews to use the VHF COM 2 radio to broadcast and receive on local frequencies during operations at non-controlled aerodromes. This reduced the ground-based radio transmission and reception strength, and therefore reduced the likelihood of other aircraft receiving calls in some circumstances.

Issue Status
Closed – Partially addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport