Date:
Issue number
Safety issue title
Crew risk awareness
Safety Issue Description

Although required by the harness instrument commonly issued by the Civil Aviation Safety Authority, the operator did not appraise shooting crews of the risks of using only a harness for restraint during low-level flight.

Issue Owner
Jayrow Helicopters
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Harness instrument clarity
Safety Issue Description

A harness instrument, commonly issued by the Civil Aviation Safety Authority (CASA), stated that a harness could be used instead of a seatbelt for take-off and landing. Although not intended by CASA, this instrument was easily able to be misinterpreted as indicating that a seatbelt was not required to be used during take-off and landing.

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
Aerial platform shooter emergency training
Safety Issue Description

Recurrency training and drills in aircraft emergencies were not required for reissue of an aerial platform shooting permission. Some shooters last conducted training about 20 years prior, during initial issue of their permissions.

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
The Director of National Parks' risk management
Safety Issue Description

The Director of National Parks did not actively manage the risk of the aerial culling task being conducted in the Kakadu National Park, or effectively supervise the operation. As a result, an increase in the number of crew, a change in helicopter type and change of helicopter operator all progressed without requisite risk management. This exposed crew to avoidable harm during low-level aerial shooting operations.

Issue Owner
Director of National Parks
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Helmet provision and use
Safety Issue Description

Although the Director of National Parks’ safe operating procedures required shooters and spotters to wear helmets during aerial culling tasks, helmets were not provided or used on a routine basis.

Issue Owner
Aviation: General aviation
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Fitment of recording devices in light aircraft - International Civil Aviation Organization
Safety Issue Description

Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in important safety issues not being identified, which may remain a hazard to current and future passenger carrying operations

Issue Owner
International Civil Aviation Organization
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
No regulatory requirement for carbon monoxide detectors
Safety Issue Description

There was no regulatory requirement from the Civil Aviation Safety Authority for piston‑engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Not addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Fitment of recording devices in light aircraft – Civil Aviation Safety Authority
Safety Issue Description

Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non‑identification of safety issues, which continue to present a hazard to current and future passenger-carrying operations.

Issue Owner
Civil Aviation Safety Aviation
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
No monitoring for carbon monoxide detector serviceability
Safety Issue Description

Although detectors were not required to be fitted to their aircraft, Sydney Seaplanes had no mechanism for monitoring the serviceability of the carbon monoxide detectors.

Issue Owner
Sydney Seaplanes
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Maintenance Publications
Safety Issue Description

While the manufacturer's instructions for the zonal inspections detailed that installation blankets could be removed 'as necessary', they did not reference the insulation blanket installation procedure. This resulted in insulation blankets not being secured to the structure.

Issue Owner
Fokker Services
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Compressor turbine blade failure
Safety Issue Description

Pratt & Whitney Canada (PWC) PT6A-114A engines fitted with compressor turbine vane rings that have been repaired in accordance with the United States Federal Aviation Administration‑approved scheme STI 72-50-254 have a significantly increased likelihood of CMSX-6 compressor turbine blade fracture and subsequent failure of the engine compared to those engines fitted with PWC‑manufactured compressor turbine vane rings.

Issue Owner
United States Federal Aviation Administration
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Runway verification cues
Safety Issue Description

Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.

Issue Owner
Virgin Australia Airlines
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Timing of 'before take-off' procedure
Safety Issue Description

Virgin Australia Airlines did not require ATR flight crews to complete the Before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying was critical.

Issue Owner
Virgin Australia Airlines
Transport Function
Aviation: Air transport
Date issue released
Issue Status
No longer relevant
Mode of Transport
Aviation
Issue number
Safety issue title
Pilot’s operating handbook
Safety Issue Description

The Robinson R44 pilot’s operating handbook low rotor RPM recovery procedure did not include reference to the minimum power airspeed for the helicopter as a consideration, which may assist a pilot to recover from a low rotor RPM condition. [Safety Issue]

Issue Owner
Robinson Helicopter Company
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Not addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Passenger scales
Safety Issue Description

Professional Helicopter Services did not have a calibration schedule for their passenger scales, which were under-reading. This increased the risk of their helicopters not achieving their expected take-off performance.

Issue Owner
Professional Helicopter Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Inhibition of safety alerts for combined air traffic control roles
Safety Issue Description

Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combined roles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation alert or runway incursion alert at their workstation.

Issue Owner
Airservices Australia
Transport Function
Aviation: Airspace management
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Location and design of taxiway J2 at Perth Airport
Safety Issue Description

The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient to effectively reduce the risk of a runway incursion.  

Issue Owner
Perth Airport Pty Ltd
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator guidance for flight crew briefing of aerodrome hot spots
Safety Issue Description

Although Qantas provided detailed guidance to flight crews about the content of departure and approach briefings, it did not specifically require aerodrome hot spots to be briefed.

Issue Owner
Qantas Airways
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Unclear procedures in Aircraft Maintenance Manual
Safety Issue Description

The procedures in the aircraft maintenance manual relating to chip detector debris analysis were written in a way that could cause confusion and error. This probably influenced the actions of the maintenance personnel to release the aircraft to service with a deteriorating bearing.

Issue Owner
Pratt & Whitney Canada
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Power turbine shaft corrosion
Safety Issue Description

The power turbine shaft in Pratt & Whitney Canada PW100 series engines operating in certain marine environments is susceptible to corrosion pitting, which can grow undetected between scheduled inspections. This increases the risk of shaft fracture resulting in engine failure.

Issue Owner
Pratt & Whitney Canada
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation