Date:
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
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
Open – Safety action pending
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
Issue number
Safety issue title
Regulatory guidance for stabilised approach criteria
Safety Issue Description

Although an applicable height of 1,000 ft for stabilised approach criteria in instrument meteorological conditions has been widely recommended by organisations such as the International Civil Aviation Organization for over 20 years, the Civil Aviation Safety Authority had not provided formal guidance information to Australian operators regarding the content of stabilised approach criteria.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Regulatory requirements for TAWS
Safety Issue Description

The Australian requirements for installing a terrain avoidance and warning system (TAWS) were less than those of other comparable countries for some types of small aeroplanes conducting air transport operations, and the requirements were not consistent with International Civil Aviation Organization (ICAO) standards and recommended practices. More specifically, although there was a TAWS requirement in Australia for turbine-engine aeroplanes carrying 10 or more passengers under the instrument flight rules:

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s risk controls to mitigate CFIT risk
Safety Issue Description

Although the operator had specified a flight profile for a straight-in approaches and stabilised approach criteria in its operations manual, and encouraged the use of stabilised approaches, there were limitations with the design of these procedures.

Issue Owner
Air Connect Australia
Transport Function
Aviation: Air transport
Date issue released
Issue Status
No longer relevant
Mode of Transport
Aviation
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