Date:
Issue number
Safety issue title
Inadequate traffic alert and collision avoidance training
Safety Issue Description

The helicopter operator's traffic alert and collision avoidance system knowledge was inadequate with respect to resolution advisory alert terrain considerations and the required intensity of response manoeuvring.

Issue Owner
Babcock Mission Critical Services Australia
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
External aircraft 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., This delayed the identification and recovery from the unsafe aircraft state resulting in the pilot not identifying the developing rate of descent during the incident, delaying the recovery from the descent.

Issue Owner
Helicorp Pty Ltd
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
ERSA procedure
Safety Issue Description

The En-Route Supplement Australia included a requirement to add 1,000 ft to the prescribed practice instrument approach ‘altitude’ at Mangalore Airport. The procedure did not detail whether this height was to be applied to the minimum descent altitude or to all approach altitudes, resulting in varied application and an increased risk of traffic conflicts. (Safety issue).

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
Ballina airport safety review
Safety Issue Description

The Civil Aviation Safety Authority review of the airspace surrounding Ballina Byron Gateway Airport did not include data for aircraft transiting the airspace without using the airport. Therefore, the risk associated with occurrences such as this one were not specifically considered when assessing the appropriate airspace classification.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Airspace management
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Lido airport operational information
Safety Issue Description

The Lido airport operational information did not include the Australian Aeronautical Information Publication (AIP) advice to fit pitot probe covers at Brisbane Airport (related to significant mud wasp activity), as well as other safety AIP information.

Issue Owner
Lufthansa Systems
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Change and risk management processes
Safety Issue Description

Malaysia Airlines’ processes for the management of change did not follow recommended industry practices, and its risk and change management processes were not detailed and clear enough to assure:

  • the appropriate level of involvement of subject matter expertise and safety groups
  • that risk controls were implemented and monitored.
Issue Owner
Malaysia Airlines
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Guidance about the use of pitot covers
Safety Issue Description

Malaysia Airlines did not develop and disseminate guidance and procedures about the use of pitot probe covers to flight crews and engineers, and there was limited awareness among those groups of the need for pitot probe covers at Brisbane Airport.

Issue Owner
Malaysia Airlines
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Interim engineering arrangements
Safety Issue Description

Malaysia Airlines did not clearly specify the division of engineering responsibilities between Malaysia Airlines and Aircraft Maintenance Services Australia engineers at Brisbane, leading to ambiguity with regard to who should conduct the final walk-around portion of the transit check. This risk was increased by the operator commencing and continuing flights to Brisbane with interim ground handling and engineering arrangements that varied from

Issue Owner
Malaysia Airlines
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Malaysia Airlines inconsistent walk-arounds
Safety Issue Description

Malaysia Airlines flight crew and engineers did not fully complete the required aircraft inspections.

Issue Owner
Malaysia Airlines
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Menzies audits of dispatch coordination tasks
Safety Issue Description

Menzies Aviation staff did not consistently carry out the required arrival and pre-departure aircraft checks of Malaysia Airlines aircraft, and Menzies Aviation audit processes were not effective at evaluating compliance with these requirements.

Issue Owner
Menzies Aviation
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Aircraft Maintenance Services Australia tool control
Safety Issue Description

Aircraft Maintenance Services Australia did not have a reliable method to account for tooling and equipment (such as pitot probe covers) prior to aircraft dispatch when providing non-certifying engineering support.

Issue Owner
Heston MRO
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Aircraft Maintenance Services Australia use of pitot covers
Safety Issue Description

Some Aircraft Maintenance Services Australia (AMSA) engineers extended the use of pitot probe covers (to mitigate the threat of wasp infestation) to operators that did not explicitly require it, including Malaysia Airlines. This increased the likelihood of error associated with the use of pitot probe covers was because AMSA engineers were not controlling or conducting all of the engineering activities and were not permitted to make technical log entries.

Issue Owner
Heston MRO [Aircraft Maintenance Services Australia was rebranded as Heston MRO in February 2019.]
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Pitot probe cover characteristics
Safety Issue Description

Although suitable for use in most situations, the streamers attached to the pitot probe covers supplied and used for A330 operations by Aircraft Maintenance Services Australia provided limited conspicuity due to their overall length, position above eye height, and limited movement in wind. This reduced the likelihood of incidental detection of the covers, which is important during turnarounds.

Issue Owner
Heston MRO [Aircraft Maintenance Services Australia was rebranded as Heston MRO in February 2019.]
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Alerts associated with nil or unreliable airspeed during take-off
Safety Issue Description

In the Airbus A330, there was no auditory alert associated with nil or unreliable airspeed from two or more sources during take-off (a high workload, critical phase of flight). Comparatively, other critical failures provide both visual and auditory indications.

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
Instruction and guidance for unreliable airspeed on take-off
Safety Issue Description

The Airbus guidance provided in the flight crew techniques manual and other manuals for helping A330 flight crews decide whether to continue or reject a take-off did not refer to unreliable airspeed indications.

Issue Owner
Airbus
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Crack initiated during manufacture
Safety Issue Description

During the manufacture of the apex pin, the initial machined profile led to unintended stress concentrations at the quench stage of the material heat treatment process that resulted in the part cracking. The crack was not removed by the final machining process.

Issue Owner
Safran Landing Systems
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Regulatory management of repeat safety findings
Safety Issue Description

The Civil Aviation Safety Authority’s acquittal process for repeat safety findings was not effective in ensuring that all previous findings of a similar nature were also appropriately assessed prior to the current and all associated safety findings being acquitted.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Hazard identification
Safety Issue Description

Airlines of Tasmania's safety management processes for identifying hazards extensively relied on safety reports. This limited the opportunity to proactively identify the risks in all operational activities, and assess the effectiveness of any controls in place.

Issue Owner
Airlines of Tasmania [Par Avion]
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
South-west operations guidance
Safety Issue Description

Airlines of Tasmania did not provide any documented guidance for the south-west operations, despite encouraging pilots to commence the flight, even when forecasts indicated they may be likely to encounter adverse weather en route. This resulted in the pilots having varied understanding of the expectations regarding in‑flight weather‑related decision making at the Arthur Range saddle, and increased the risk that some pilots continued into an area of high terrain in marginal conditions, where options to escape were limited.

Issue Owner
Airlines of Tasmania
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Risk assessment for lifting operations
Safety Issue Description

GHD's documented risk assessment for helicopter operations did not consider the hazard of an emergency landing at the drill site. This increased the risk that ground personnel were not clear of the load pick-up area in the event an emergency landing was required.

Issue Owner
GHD Limited
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation