Date Issue Released
Output Number
Title
AO-2009-053-SAN-038
Organisation
Operators of CFM56-7 and CFM56-5 engines
Date released
Approval Date
Status
Closed
Recommendation type
Output Number
Title
AO-2009-032-SAN-019
Organisation
Operators and pilots
Date released
Approval Date
Status
Closed
Recommendation type
Issue number
Safety issue title
CASA Documentation
Safety Issue Description

The flight planning requirements at page 88 of the Visual Flight Guide included a transcription error that inadvertently limited the application of the requirements of Civil Aviation Regulation 239.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Other
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Flight Review guidance
Safety Issue Description

The current advice in Civil Aviation Advisory Publication 5.81-1(0) Flight Crew Licensing Flight Reviews in relation to the assessment of navigation skills, represents a missed opportunity to identify a pilot's capacity to make safe and appropriate decisions during cross country flying.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Robinson-specific training
Safety Issue Description

There was no Australian requirement for endorsement and recurrent training conducted on Robinson Helicopter Company R22/R44 helicopters to specifically address the preconditions for, recognition of, or recovery from, low main rotor RPM.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Issue number
Safety issue title
Pilots operating outside level of competence
Safety Issue Description

There was a lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimised the risk of pilots operating outside the individual pilot’s level of competence.

Issue Owner
Heliwork WA Pty Ltd
Transport Function
Aviation: General aviation
Date issue released
Mode of Transport
Aviation
Output Number
Title
AO-2007-066-SR-081
Organisation
Civil Aviation Safety Authority
Date released
Approval Date
Status
Closed - Action Taken
Recommendation type
Issue number
Safety issue title
Compromised separation recovery training
Safety Issue Description

Airservices Australia’s compromised separation recovery training for Sydney tower controllers did not include scenarios involving aircraft below the minimum vector altitude at night.

Issue Owner
Airservices Australia
Transport Function
Aviation: Airspace management
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Pre-flight risk assessment
Safety Issue Description

Microflite did not provide, nor require, their pilots to complete a pre-flight risk assessment for their taskings. A pre-flight risk assessment would have provided pre‑defined criteria to ensure consistent and objective decision-making and reduced the risk of them selecting an inappropriate route.

Issue Owner
Microflite Pty Ltd
Transport Function
Aviation: Air transport
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
CASA lack of effective process
Safety Issue Description

The Civil Aviation Safety Authority (CASA) did not have an effective process for assuring an authorisation would be unlikely to have an adverse effect on safety. As a result, CASA delegates did not use the available structured risk management process to identify and assess the risks, ensure appropriate and adequate mitigations were included as conditions of the approval, or assess the effects of changes on the overall risk.

 

Issue Owner
Civil Aviation Safety Authority (CASA)
Transport Function
Aviation: General aviation
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Inadvertent instrument meteorological conditions recovery procedure and training
Safety Issue Description

Microflite had not published an inadvertent instrument meteorological conditions (IIMC) recovery procedure for their day visual flight rules pilots and their IIMC recovery training was not mandatory. The provision of this procedure and training would have reduced the risk of a loss of attitude control following an IIMC encounter.

Issue Owner
Microflite Pty Ltd
Transport Function
Aviation: Air transport
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator proficiency check requirements
Safety Issue Description

The Microflite Operator Proficiency Checks did not include a mandatory instrument flight component for their day visual flight rules pilots. This would have reduced the risk of a loss of control event following an inadvertent instrument meteorological conditions encounter.

Issue Owner
Microflite Pty Ltd
Transport Function
Aviation: Air transport
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Risk management of specific threat scenarios
Safety Issue Description

Although Airservices Australia applied operational risk assessments to high-level threats, it did not formally assess and manage the risk of specific threat scenarios. As a likely result, Airservices did not formally identify and risk manage the threat of separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport, even though it had been a known issue among controllers generally.

Issue Owner
Airservices Australia
Transport Function
Aviation: Airspace management
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Manufacturer test procedures
Safety Issue Description

The balloon manufacturer did not have an adequate process to verify the accuracy of the temperature recorded during production inflation tests.

Issue Owner
Kubicek Balloons
Transport Function
Aviation: Air transport
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Absence of procedural controls to separate aircraft below the minimum vector altitude at night when on identified conflicting flight paths
Safety Issue Description

Airservices Australia did not have procedural controls to separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport while below the minimum vector altitude at night. 

Issue Owner
Airservices Australia
Transport Function
Aviation: Airspace management
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Civil Aviation Safety Regulations Part 133 requirements
Safety Issue Description

The Civil Aviation Safety Authority's Part 133 (air transport - rotorcraft) exposition requirements did not adequately address the risk to passenger safety from a visual flight rules inadvertent instrument meteorological conditions event.

CASA response

On 21 November 2023, the Civil Aviation Safety Authority advised the ATSB that:

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Helibrook inadequate safety management
Safety Issue Description

Helibrook’s approved safety management system was not being used to systematically identify and manage operational hazards. As a result, risks associated with conducting human external cargo operations such as carriage of the egg collector above a survivable fall height were not adequately addressed.

Response by Helibrook

Issue Owner
Helibrook Pty Ltd
Transport Function
Aviation: General aviation
Issue Status
No longer relevant
Mode of Transport
Aviation
Issue number
Safety issue title
Risk management of specific threat scenarios
Safety Issue Description

Although Airservices Australia used applied operational risk assessments to high-level threats, it did not formally assess and manage the risk of specific threat scenarios. As a likely result, Airservices did not formally identify and risk manage the threat of separate aircraft concurrently carrying out the MARUB SIX standard instrument departure and a missed approach from runway 34R at Sydney Airport, even though it had been a known issue among controllers generally.

Issue Owner
Airservices Australia
Transport Function
Aviation: Airspace management
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Training provided on flare height
Safety Issue Description

The training provider, contracted by the operator to conduct Boeing 737 conversion training, was training pilots to flare at 30 ft rather than the manufacturer’s requirement of 20 ft. This increased the risk of unstable and/or hard landings.

Issue Owner
CAE
Transport Function
Aviation: Air transport
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Separation assurance of concurrent procedures
Safety Issue Description

The Airservices Australia MARUB SIX standard instrument departure and the missed approach procedure for runway 34R directed aircraft onto outbound tracks that did not sufficiently assure separation between aircraft following the procedures concurrently.

Issue Owner
Airservices Australia
Transport Function
Aviation: Airspace management
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation