Date Issue Released
Issue number
Issue Owner
All high capacity operators
Safety issue title
Instructions to wear seat belts in cruise
Safety Issue Description

Although passengers are routinely advised after takeoff to wear their seat belts when seated, this advice typically does not reinforce how the seat belts should be worn.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
All high capacity operators
Safety issue title
Single event effect general risk to avionics
Safety Issue Description

Single event effects (SEE) have the potential to adversely affect avionics systems that have not been specifically designed to be resilient to this hazard. There were no specific certification requirements for SEE, and until recently there was no formal guidance material available for addressing SEE during the design process.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Northrop Grumman Corporation
Safety issue title
Air data inertial reference unit (ADIRU) fault detection
Safety Issue Description

For the data-spike failure mode, the built-in test equipment of the LTN 101 air data inertial reference unit was not effective, for air data parameters, in detecting the problem, communicating appropriate fault information, and flagging affected data as invalid.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
US Federal Aviation Administration
Safety issue title
Take-off decision making philosophy
Safety Issue Description

The existing take-off certification standards, which were based on the attainment of the take-off reference speeds, and flight crew training that was based on monitoring of and responding to those speeds, did not provide crews a means to detect degraded take-off acceleration.

Issue Status
Closed – Partially addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Emirates
Safety issue title
Distraction management processes
Safety Issue Description

The operator’s training and processes in place to enable flight crew to manage distractions during the pre-departure phase did not minimise the effect of distraction during safety critical tasks.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Civil Aviation Safety Authority and Operators of M18 Dromader aircraft
Safety issue title
Recording of service life factors
Safety Issue Description

A number of operators of the PZL M-18 Dromader aircraft had not applied the appropriate service life factors to the aircraft’s time in service for operations conducted with take-off weights greater than 4,700 kg, as required by the aircraft’s service documentation. Hence the operators could not be assured that their aircraft were within their safe service life.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Civil Aviation Safety Authority
Safety issue title
CASA exemptions do not provide adequate level of safety
Safety Issue Description

Operation of the M-18A in accordance with Civil Aviation Safety Authority exemptions EX56/07 and EX09/07 at weights in excess of the basic Aircraft Flight Manual maximum take-off weight (MTOW), up to the MTOW listed on the Type Certificate Data Sheet, may not provide the same level of safety intended by the manufacturer when including that weight on the Type Certificate.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Airbus
Safety issue title
Flight Data Recorder rack
Safety Issue Description

The failure of the digital flight data recorder (DFDR) rack during the tail strike prevented the DFDR from recording subsequent flight parameters.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Emirates
Safety issue title
Flight plan document design
Safety Issue Description

The lack of a designated position in the pre-flight documentation to record the green dot speed precipitated a number of informal methods of recording that value, lessening the effectiveness of the green dot check within the loadsheet confirmation procedure.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Wayport Pty Ltd
Safety issue title
Organisational Operations Manual and Safety Management Systems
Safety Issue Description

The lack of a requirement for a charter-specific risk assessment in this case meant that the risks associated with the charter were not adequately addressed.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Civil Aviation Safety Authority
Safety issue title
Commercial balloon procedural and guidance framework
Safety Issue Description

The procedural and guidance framework for commercial balloon operations generally, did not provide a high level of assurance in regard to the safe conduct of low flying.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Society of Automotive Engineers
Safety issue title
Society of Automotive Engineers specification
Safety Issue Description

The Society of Automotive Engineers specification AS7477 was ambiguous in relation to the requirement to cold roll the head-to-shank fillet radius of MS9490-34 bolts.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Pratt and Whitney (Canada)
Safety issue title
Non-cold rolled bolts into service
Safety Issue Description

A number of non-cold rolled bolts were installed on PT6A-67 series engines during manufacture and overhaul

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Civil Aviation Safety Authority
Safety issue title
Maintenance for repetitve lift missions
Safety Issue Description

The scheduled maintenance requirements for ex-military UH-1 series helicopters may not adequately address the increased risk of fatigue failures associated with repetitive heavy lifting operations that were not considered in the original design fatigue calculations.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Qantas Airways
Safety issue title
Monitoring of landing gear through Flight Operational Quality Assurance
Safety Issue Description

There were no soft and hard triggers in the operator’s Flight Operational Quality Assurance system to monitor the selection of the aircraft’s landing gear during an approach.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways
Safety issue title
Inconsistent monitoring messages in company documentation
Safety Issue Description

The conflicting requirements and definitions in the operator’s publications in relation to the pilot not flying role had the potential to diminish the importance of monitoring as an essential element in an aircraft’s safe operation.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways
Safety issue title
Correlation between flight data and incident reports
Safety Issue Description

There was no correlation between the results of the operator’s Flight Operational Quality Assurance and Air Safety Incident Report investigations.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Airbus Industrie
Safety issue title
Windshield terminal block failure
Safety Issue Description

Windshields manufactured with terminal block fittings containing polysulfide sealant (PR1829) have been shown to be predisposed to premature overheating failure that could lead to the development of a localised fire.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Raytheon Aircraft Co
Safety issue title
Replacement of cabin altitude warning switch
Safety Issue Description

The aircraft maintenance manuals did not include the operating specifications of the replacement cabin altitude warning pressure switch hampering the required verification of switch serviceabilty.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Raytheon Aircraft Co
Safety issue title
Cabin Altitude Warning switc wiring diagram
Safety Issue Description

The cabin altitude warning pressure switch maintenance manual wiring diagram did not provide a clear indication of the wiring connections for the superseded switch.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance