Date:
Issue number
Safety issue title
Balloon passenger briefing procedures
Safety Issue Description

Although the operator had procedures for conducting a verbal safety briefing prior to flight and had safety briefing cards available, its risk controls did not provide assurance that all passengers would understand the required procedures for emergency landings. More specifically:

Issue Owner
Go Wild Ballooning Pty Ltd
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Procedures for uploading balloon forecasts
Safety Issue Description

The Bureau of Meteorology did not have a procedure to ensure that a recording of the local weather forecast for balloon operations in the Melbourne area was correctly uploaded and accessible to balloon pilots.

Issue Owner
Bureau of Meteorology
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Lack of inspection method to detect fracture
Safety Issue Description

The engine manufacturer did not have specific inspection procedures in the maintenance documents of the propeller shaft to detect a fatigue crack originating from the dowel pin hole.

Issue Owner
General Electric (GE)
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
In-flight landing distance safety margin may be inadequate
Safety Issue Description

Civil Aviation Order 20.7.1B stipulated that a 1.15 (15 per cent) safety margin was to be applied to the actual landing distance for jet-engine aircraft with a maximum take-off weight greater than 5,700 kg. This safety margin may be inadequate under certain runway conditions, which increases the risk of a runway excursion. The corresponding guidance in Civil Aviation Advisory Publication 235-5(0) had not been updated to account for this.

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
Cross-checking environmental information and landing performance
Safety Issue Description

Virgin Australia Airlines/Virgin Australia International did not have a policy requiring crews to independently cross-check environmental information and landing performance calculations in-flight, removing an opportunity to detect crew errors.

Issue Owner
Virgin Australia Airlines/Virgin Australia International
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Lack of regulatory direction
Safety Issue Description

There was no regulatory direction from the Civil Aviation Safety Authority on how a damp runway was to be considered for aircraft landing performance.

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
Incorporation: change in damp definition
Safety Issue Description

Several months prior to the incident, Virgin Australia Airlines/Virgin Australia International changed their policy on calculating landing performance for damp runways from referencing a wet runway to a dry runway.

Issue Owner
Virgin Australia Airlines/Virgin Australia International
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Hazard associated with the inability to separate aircraft below the appropriate lowest safe altitude at night
Safety Issue Description

The hazard associated with the inability to separate aircraft that are below the appropriate lowest safe altitude at night was identified but not adequately mitigated. This resulted in a situation where, in the event of a simultaneous go-around at night during land and hold short operations at Melbourne Airport, there was no safe option available to air traffic controllers to establish a separation standard when aircraft were below minimum vector altitude.

Issue Owner
Airservices Australia
Transport Function
Aviation: Airspace management
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Air Operator Certificate holder fuel policy requirements
Safety Issue Description

The current legislation does not require commercial operators of aircraft not greater than 5,700 kg maximum take-off weight to provide instructions and procedures for crosschecking the quantity of fuel on board before and/or during flight. This increases the risk that operators in this category will not implement effective fuel policies and training to prevent fuel exhaustion events.

Issue Owner
Civil Aviation Safety Authority (CASA)
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Helicopter underwater escape training
Safety Issue Description

The Australian Transport Safety Bureau advises helicopter operators involved in overwater operations of the importance of undertaking regular HUET (helicopter underwater escape training) for all crew and regular passengers to increase their survivability in the event of an in-water accident or ditching.

Safety Advisory Notice for all helicopter operators engaged in overwater operations

 

Issue Owner
All overwater helicopter operators
Transport Function
Aviation: Other
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Autopilot advice, limitations cautions and warnings (written and audible)
Safety Issue Description

The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.

Issue Owner
Cessna Aircraft Company (Textron)
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Autopilot advice, limitations cautions and warnings (written and audible)
Safety Issue Description

The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.

Issue Owner
Garmin
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Elevated risk from non-precision approach with low-level circling and non-stabilised approach procedure
Safety Issue Description

The operator commenced regular public transport operations into Kosrae with the only instrument approach available for use being an offset procedure based on a non-precision navigation aid. The risk associated with this type of approach was amplified due to the need to use a 'dive and drive' style technique instead of a stable approach path, and that it required low level circling manoeuvring from the instrument approach to align the aircraft with the runway.

Issue Owner
Nauru Airlines
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Safety reporting culture and procedures
Safety Issue Description

The operator's documented procedure for company personnel to report accidents and incidents was in itself not sufficient to ensure that occurrences that had affected, or had the potential to affect safety, were reported to management. This decreased the opportunity for the operator to identify potential operational risks and take appropriate action to minimise them.

Issue Owner
Rebel Ag Pty Ltd
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Guidance information on the limitations of FAID
Safety Issue Description

Guidance material associated with the FAID bio-mathematical model of fatigue did not provide information about the limitations of the model when applied to roster patterns involving minimal duty time or work in the previous 7 days.

Issue Owner
InterDynamics
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Regulatory surveillance – assessing process in practice
Safety Issue Description

Consistent with widely-agreed safety science principles, the Civil Aviation Safety Authority’s approach to surveillance of larger charter operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the actual conduct of line operations (or ‘process in practice’).

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Regulatory surveillance – scoping of audits
Safety Issue Description

The Civil Aviation Safety Authority’s procedures and guidance for scoping an audit 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
Regulatory surveillance – surveillance planning
Safety Issue Description

Although the Civil Aviation Safety Authority (CASA) collected or had access to many types of information about a charter and/or aerial work operator, the information was not integrated to form a useful operations or safety profile of the operator. In addition, CASA’s processes for obtaining information on the nature and extent of an operator’s operations were limited and informal. These limitations reduced its ability to effectively prioritise surveillance activities.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Classification of air ambulance operations
Safety Issue Description

Although air ambulance flights involved transporting passengers, in Australia they were classified as ‘aerial work’ rather than ‘charter’. Consequently, they were subject to a lower level of regulatory requirements than other passenger-transport operations (including requirements for fuel planning flights to remote islands).

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Regulatory requirements and guidance for in-flight fuel management
Safety Issue Description

The available regulatory guidance on in-flight fuel management and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation