Date Issue Released
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
Issue number
Safety issue title
Policies and procedures for planning IFR and NVIS flights
Safety Issue Description

Although CHC Helicopter Australia’s operations manual stated that emergency medical service flights should be conducted under instrument flight rules (IFR) ‘where practical’, its procedures for night visual flight rules (NVFR) operations using night vision goggles did not clearly state when IFR rather than NVFR should be used.

 

Issue Owner
CHC Helicopter Australia
Transport Function
Aviation: Air transport
Date issue released
Mode of Transport
Aviation
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