Date:
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
Issue number
Safety issue title
Balloon visual meteorological conditions
Safety Issue Description

The visual flight rules permitted balloons to arrive and depart in foggy conditions without assurance that sufficient visibility existed to see and avoid obstacles.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Not addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Maintenance practices
Safety Issue Description

Cloncurry Air Maintenance had adopted a number of practices, which included using abbreviated inspection checklists, not recording all flight control disturbances and not progressively certifying for every inspection item as the work was completed, which increased the risk of memory-related errors and the omission of tasks.

Issue Owner
Cloncurry Air Maintenance
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Inspection period for blade cracking
Safety Issue Description

The scheduled inspections recommended by Rolls-Royce to detect cracking in Trent 700 fan blades, were insufficient to detect early onset fatigue cracks in the membrane to panel bond before those cracks could progress to failure.

Issue Owner
Rolls-Royce plc
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Fatigue cracking of Trent 700 fan blades
Safety Issue Description

The Trent 700 blade manufacturing process produced a variation in internal membrane-to-panel acute corner geometry that, in combination with the inherent high level of blade panel stress, could lead to increased localised stresses in those corner areas and the initiation and propagation of fatigue cracking.

Issue Owner
Rolls-Royce plc
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Guidance on vehicle-assisted deflation risks
Safety Issue Description

The Civil Aviation Safety Authority provided no guidance for operators concerning the risks associated with vehicle‑assisted deflation.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Risk management processes
Safety Issue Description

Picture This Ballooning's safety risk management processes and practices were not sufficient to facilitate the identification of key operational risks associated with vehicle-assisted deflation.

Issue Owner
Picture This Ballooning
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Vehicle-assisted deflation procedures
Safety Issue Description

Picture This Ballooning did not have any procedures for conducting vehicle-assisted deflation.

Issue Owner
Picture This Ballooning
Transport Function
Aviation: Other
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Pilatus PC-12 trim and flap interrupt switches
Safety Issue Description

The similarities between the Trim Interrupt and Flap Interrupt switches and the proximal location of the two switches unnecessarily increased the risk of mis-selection and contributed to the excessive out-of-trim condition.

Issue Owner
Pilatus Aircraft Ltd
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Cicaré S.A. CH-7T/B/BT service bulletin
Safety Issue Description

The Cicaré 7T/B/BT mandatory service bulletin (BSC007) for the general stabiliser support assembly provided limited guidance for disassembly of the manufactured component and did not stipulate a compliance period within which to perform the inspection nor provide consideration for repeat inspections. This potentially reduced the opportunity to detect the presence of crack initiation and growth in the stabiliser support assembly.

Issue Owner
Cicaré S.A.
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Passenger oxygen mask instructions
Safety Issue Description

The pre-flight safety briefing and safety information card did not include a clear instruction on how to activate the flow of oxygen from the passenger oxygen masks and that the bag may not inflate when oxygen is flowing. This resulted in some passengers not understanding whether or not there was oxygen flowing in the mask.

Issue Owner
AirAsia Indonesia
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Air display approval and oversight
Safety Issue Description

The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors:

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Other
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Advantage 70 engine modification
Safety Issue Description

There were a total of 16 engine malfunction events globally over a 4-year period attributed to modification of the Advantage 70™ engine. The modification increased the engine outer duct gas path temperature, which led to distortion and liberation of the outer transition duct segments.

Issue Owner
Pratt & Whitney
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
CASA ALA guidance on runway overrun areas
Safety Issue Description

The Civil Aviation Advisory Publication for Aeroplane Landing Areas (92-1(1)) did not have guidance for the inclusion of a safe runway overrun area.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Regulatory surveillance – scoping of surveillance events
Safety Issue Description

The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Requirements for briefing the brace position in small aircraft
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 brace position for an emergency landing or ditching, even for aircraft without upper torso restraints fitted to all passenger seats.

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
Requirements for upper torso restraints in small aircraft
Safety Issue Description

Upper torso restraints (UTRs) were not required for all passenger seats for small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992, including for passenger transport operations. Although options for retrofitting UTRs are available for many models of small aircraft, many of these aircraft manufactured before the applicable dates that are being used for passenger transport have not yet been retrofitted.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s processes for reviewing its operations
Safety Issue Description

There were a significant number and variety of problems associated with the operator’s activities that increased safety risk, and the operator’s chief pilot held all the key positions within the operator’s organisation and conducted most of the operator’s flights. Overall, there were no effective mechanisms in place to regularly and independently review the suitability of the operator’s activities, which enabled flight operations to deviate from relevant standards.

Issue Owner
Wyndham Aviation Pty Ltd
Transport Function
Aviation: Air transport
Date issue released
Issue Status
No longer relevant
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s conduct of near-aerobatic manoeuvres during charter flights
Safety Issue Description

The operator’s pilots routinely conducted near-aerobatic manoeuvres during passenger charter flights. However, procedures for these manoeuvres were not specified in the operator’s Operations Manual, and there were limited controls in place to manage the risk of these manoeuvres.

Issue Owner
Wyndham Aviation Pty Ltd
Transport Function
Aviation: Air transport
Date issue released
Issue Status
No longer relevant
Mode of Transport
Aviation
Issue number
Safety issue title
Operator’s practices for securing baggage and other cargo
Safety Issue Description

Although the operator’s procedures required that baggage and cargo be secured during flight, this procedure was routinely not followed, and the aircraft were not equipped with cargo nets or other means for securing loads in the baggage compartment.

Issue Owner
Wyndham Aviation Pty Ltd
Transport Function
Aviation: Air transport
Date issue released
Issue Status
No longer relevant
Mode of Transport
Aviation