Date:
Issue number
Safety issue title
Operator’s aircraft loading practices
Safety Issue Description

Although the operator’s procedures required that actual weights be used for passengers, baggage and other cargo, this procedure was routinely not followed, and pilots relied on estimated weights when calculating an aircraft’s weight and balance.

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 procedures and practices for airborne inspections of a landing area
Safety Issue Description

The operator normally conducted airborne inspections of the Middle Island aeroplane landing area at about 50–100 ft while flying at normal cruise speed towards an area of water, and its procedures did not ensure the effective management of the risk of an engine failure or power loss when at a low height.

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
Regulatory differentiation between community service flying and private operations
Safety Issue Description

The Civil Aviation Safety Authority did not have a system to differentiate between community service flights and other private operations, which limited its ability to identify risks. This hindered the Civil Aviation Safety Authority's ability to manage risks associated with community service flights.

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
Availability of safety information to Angel Flight Australia
Safety Issue Description

There were limited opportunities for Angel Flight to be made aware of any safety related information involving flights conducted on its behalf.

Issue Owner
Angel Flight Australia
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Insufficient organisational risk controls implemented by Angel Flight Australia
Safety Issue Description

Angel Flight had insufficient controls in place, and provided inadequate guidance to pilots to address the additional operational risks associated with community service flights.

Issue Owner
Angel Flight Australia
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Angel Flight Australia consideration of commercial flights
Safety Issue Description

Angel Flight did not consider the safety benefits of commercial passenger flights when suitable flights were available.

Issue Owner
Angel Flight Australia
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Not addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Undetected horizontal stabiliser damage in world fleet
Safety Issue Description

As a legacy of there being no inspection specific to an in-flight pitch disconnect, there is potential for other ATR aircraft to have sustained an in-flight pitch disconnect in the past and be operating with undetected horizontal stabiliser damage.

Issue Owner
ATR
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Maintenance requirements following an in-flight pitch disconnect
Safety Issue Description

The aircraft manufacturer, ATR, did not provide a maintenance inspection to specifically assess the effect of an in-flight pitch disconnect on the structural integrity of the horizontal stabilisers. As a result, if an in-flight pitch disconnect occurred, the aircraft may not be inspected at a level commensurate with the criticality of the event.

Issue Owner
ATR
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
No consideration of dual control inputs on aircraft response in the design standard
Safety Issue Description

Although the design standard for the aircraft (JAR-25) required the control system to be of sufficient strength to withstand dual control inputs, it did not require consideration of the effect that dual control inputs may have on control of the aircraft. Similarly, the current design standard (CS-25) does not address this issue.

Response from EASA

In September 2018, EASA advised the ATSB that:

Issue Owner
European Aviation Safety Agency (EASA)
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
No consideration of transient control loads in the design standard
Safety Issue Description

The design standard for large transport aircraft, Joint Aviation Requirements - Part 25 (JAR-25), did not require that the demonstrated potential for flexibility in the control system to develop transient dynamic loads, be considered during certification. Similarly, the current certification standard for Large Aeroplanes (CS-25) does not address this issue.

Issue Owner
European Aviation Safety Agency (EASA)
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Effect of dual control inputs on elevator response
Safety Issue Description

Flexibility in the ATR 72’s pitch control system between the control columns results in a change in the aircraft’s longitudinal handling qualities and control dynamics when dual control inputs are made. This could result in an aircraft-pilot coupling event where flight crew may find it difficult to control the aircraft.

Issue Owner
ATR
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Reduced flight control tactile feedback
Safety Issue Description

The design of the ATR 72 pitch control system resulted in limited tactile feedback between the left and right control columns, reducing the ability of one pilot to detect that the other pilot is making control inputs. In addition, there were no visual or auditory systems to indicate dual control inputs.

Issue Owner
ATR
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
En route supplement guidance to flight crews
Safety Issue Description

The En Route Supplement Australia (ERSA) did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.

Issue Owner
Darwin International Airport
Transport Function
Aviation: Airports
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Operator guidance to flight crews
Safety Issue Description

Virgin Australia did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.

Issue Owner
Virgin Australia Airlines
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Limited visual cues for approach at Darwin runway 11/29
Safety Issue Description

The absence of centreline lighting and the 60-m width of runway 11/29 at Darwin result in very limited visual cues for maintaining runway alignment during night landings in reduced visibility.

Issue Owner
Darwin International Airport
Transport Function
Aviation: Airports
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Standards for installation of runway centreline lighting on wider runways
Safety Issue Description

Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions. The installation of centreline lighting on wider category I runways is recommended but not mandated by the International Civil Aviation Organization Annex 14.

Issue Owner
International Civil Aviation Organization
Transport Function
Aviation: Airports
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
NAV ADR DISAGREE procedure
Safety Issue Description

A NAV ADR DISAGREE alert can be triggered by either an airspeed discrepancy, or angle of attack discrepancy. The alert does not indicate which, and the associated procedure may lead flight crews to incorrectly diagnosing the source of the alert when the airspeed is erroneous for a short period and no airspeed discrepancy is present when the procedure is carried out.

Issue Owner
Airbus
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Priority of NAV ADR DISAGREE alert
Safety Issue Description

Although the NAV ADR DISAGREE had more immediate safety implications relating to unreliable airspeed, the ECAM alert priority logic placed this alert below the engine-related faults. As a result, the NAV ADR DISAGREE alert was not immediately visible to the flight crew due to the limited space available on the ECAM display.

Issue Owner
Airbus
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Re-evaluating hold speeds for a change in altitude
Safety Issue Description

The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude (specifically above flight level 200).

Issue Owner
Qantas Airways
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Stall prevention and recovery at high altitudes
Safety Issue Description

The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle.

Issue Owner
Qantas Airways
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation