Date:
Issue number
Safety issue title
Maintenance practices and processes
Safety Issue Description

Encore Aviation's maintenance practices and processes related to inspections, record keeping and trend monitoring, were likely inadequate to detect the potential impending failure of safety critical components.

Issue Owner
Encore Aviation – Aircraft maintenance provider
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Guidance in the ground handling manual
Safety Issue Description

The operator's ground handling manual did not contain detailed procedural guidance for facilitating accurate redistribution of freight and ensure that an aircraft would be correctly loaded.

Issue Owner
Toll Aviation
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Fatigue damage detection inspection requirements
Safety Issue Description

Following an assessment of historical data, the aircraft manufacturer, Textron Aviation, replaced a flight hour based repetitive eddy current inspection for cracking of the carry-through structure with a three-yearly visual corrosion inspection for all operation types. This significantly limited the opportunities to identify fatigue cracking within the carry-through structure of low-level survey aircraft prior to a crack reaching a critical size.

Issue Owner
Textron Aviation
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Compliance with AD SUPP 10
Safety Issue Description

It is likely that specific post-flight inspection requirements for the Breeze Eastern rescue hoist listed in Airworthiness Directive AD/SUPP/10 were not adequately completed by the operator. The inspections were targeted at ensuring correct stowage of the hook assembly at the end of each flight.

Issue Owner
New South Wales National Parks and Wildlife Service (ParkAir)
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Regulator guidance
Safety Issue Description

Civil Aviation Safety Authority (CASA) advisory publications did not include information regarding the potential for reduction in braking performance resulting from active rainfall.

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
Operator guidance
Safety Issue Description

The operator's documentation required crew to consider contamination of runways at the departure and destination airports. However, the provided definition and guidance did not include the means to identify water contamination from active rainfall.

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
Cabin exit design criteria (Issue owner: United States Federal Aviation Administration)
Safety Issue Description

Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities.

Issue Owner
United States Federal Aviation Administration
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Not addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Cessna 206 emergency procedures
Safety Issue Description

The Cessna 206 procedure for ditching and forced landing states that the flaps are to be extended to 40°. While that permits the aircraft to land at a slower speed, it also significantly restricts emergency egress via the cargo door. However, there is no warning about that aspect in the ditching or forced landing pilot’s operating handbook emergency procedures.

Issue Owner
Textron Aviation
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Cabin exit design criteria (Issue owner: Civil Aviation Safety Authority)
Safety Issue Description

Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Not addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Maintenance manual supplement
Safety Issue Description

The inspection procedures in the West Star Aviation maintenance manual supplement for extended life program Cessna 441 aircraft were inadequate to detect the progressive disbonding of the emergency exit door.

Issue Owner
West Star Aviation
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator consolidation processes for flight crew
Safety Issue Description

Although the operator complied with the regulatory requirements for training and experience of pilots, it had limited processes in place to ensure pilots with minimal time and experience on a new and technically different helicopter type had the opportunity to effectively consolidate their skills on the type required for conducting the operator's normal operations to pontoons.

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Pilots leaving the controls of the helicopter
Safety Issue Description

It was common practice for the operator’s pilots to leave the controls of their helicopter, while the rotors were turning and the friction locks applied, to escort passengers to and from the helicopter.

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator management of birdstrikes
Safety Issue Description

There was often a significant number of birds located on the pontoons at Hardy Reef used by the operator. However, the operator did not have a process to systematically manage the risk of birdstrike. For example:

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator helicopter loading practices
Safety Issue Description

Although the operator had calibrated scales available for use at two of their check-in locations, they were not routinely used to ascertain actual passenger and/or baggage weights. Instead, the operator's personnel relied on passengers’ volunteered weights (without an additional allowance) and only weighed passengers when the volunteered weights were perceived to be inaccurate.

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Passengers with reduced mobility
Safety Issue Description

The operator’s system used to identify passengers with reduced mobility and/or required additional safety briefing information relied on passengers self-reporting a problem.

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Design of the EC120B rear left emergency exit
Safety Issue Description

Due to multiple factors, the design of the rear left sliding door (emergency exit) on the EC120B helicopter was not simple and obvious to use unless the occupant was provided with specific instructions about how to operate the exit. In particular:

  • the door required three actions to open (pull handle up, push door out, slide door back), and the second action was not indicated in either the design of the handle or the placard next to the handle
  • the design of the inside handle was such that its purpose may not have been readily apparent to many users.
Issue Owner
Airbus Helicopters
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Requirements for verbally briefing passengers on emergency exits
Safety Issue Description

There was no requirement for operators of passenger transport flights in aircraft with six or less seats to provide passengers with a verbal briefing, or written briefing material, on the method for operating the emergency exits.

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
Fuel quantity assessment methods
Safety Issue Description

Although the operator had specified multiple methods of cross-checking fuel quantity gauge indications for its C441 fleet, there were limitations in the design, definition and/or application of these methods. These included:

Issue Owner
Skippers Aviation
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Maintenance processes for landing gear
Safety Issue Description

The operator did not place appropriate emphasis on ensuring the continuing airworthiness of the landing gear of its GA8 fleet, although being aware of:

  • the increased loads on the landing gear when routinely operating from beach landing areas up to 20–30 times daily, and being subjected to a salt-laden and humid environment
  • the axle failure of VH-BFS in 2009
  • the mandatory inspection requirements of service bulletin SB-GA8-2016-169.
Issue Owner
Air Fraser Island
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Aeropower post-training supervision
Safety Issue Description

There were no requirements in Aeropower procedures to provide any post-training supervision for powerline operations. What supervision was provided was ineffective in identifying that a modified stringing method was being used by the pilot.

Issue Owner
Aeropower Pty. Ltd.
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation