Date Issue Released
Issue number
Issue Owner
Helibrook Pty Ltd
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 Status
No longer relevant
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Civil Aviation Safety Authority (CASA)
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 Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Regional Express Pty Ltd
Safety issue title
Horizontal stabiliser bung design considerations
Safety Issue Description

The design of the horizontal stabiliser bungs did not consider aspects that would ensure the identification of an installed bung, or the safe operation of the aircraft if the bungs were not removed prior to flight.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Regional Express Pty Ltd
Safety issue title
No procedure for storage and accountability
Safety Issue Description

There were no formal procedures for the storage and accountability of horizontal stabiliser bungs after they were removed from the aircraft.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Airservices Australia
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 Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Airservices Australia
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 Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Airservices Australia
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 Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Airservices Australia
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 Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Kubicek Balloons
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 Status
Closed – 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
Aircraft lighting regulation
Safety Issue Description

Regulatory requirements did not ensure that aircraft lighting was adequate to conduct night vision imaging system winching operations safely.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
TOLL
Safety issue title
Operational in-flight risk assessment guidance
Safety Issue Description

Although the operator’s procedures for winching and night vision imaging system operations included the need to have adequate hover references and a method of recovery in the event of a night vision goggle failure, there was limited guidance to ensure these requirements were confirmed by the flight crew on‑site before commencing precision hover operations.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
TOLL
Safety issue title
TOLL recency requirements
Safety Issue Description

Toll recency for night vision imaging system (NVIS) winching was insufficient to ensure that complex NVIS winching operations, such as in this occurrence, could be conducted safely.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
TOLL
Safety issue title
External white lighting
Safety Issue Description

The external aircraft white lighting was inadequate to illuminate the terrain below and to the side of the aircraft at the required operating height.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Eastern Air Link
Safety issue title
Inappropriate use of the visual approach in marginal weather
Safety Issue Description

The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions.

Issue Status
Open – Safety action pending
Date issue released
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Eastern Air Link Pty Ltd
Safety issue title
Inappropriate use of the visual approach in marginal weather
Safety Issue Description

The occurrence flight used a distance measuring equipment (DME) arrival to establish a visual approach in unsuitable visibility conditions. The investigation identified a number of similar approaches conducted by the operator in marginal visibility conditions. Using this approach method, rather than a straight in instrument approach, significantly reduced obstacle clearance assurance for both an approach and any potential missed approaches, and also increased the risk to both the operator’s and other aircraft through the use of a non-standard circuit procedure.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Airwork Flight Operations Limited
Safety issue title
Normalised, unauthorised procedure
Safety Issue Description

The aircraft system to be used in the event of a main deck cargo smoke event on the operator’s B737 fleet was being routinely used by the operator’s engineering personnel in Darwin as a means to cool the flight deck. This practice had become normalised as a result of the perceived benefit of doing so, but there were insufficient risk controls in place to ensure that the aircraft would be returned to the correct configuration prior to departure.

Issue Status
Closed – 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
CAAP 92 Guidance
Safety Issue Description

Recommendations in CASA guidance CAAP 92-1(1) requiring obstacle clearance out to 900 m may lead to circumstances where ALAs meet these requirements however, aircraft are required to manoeuvre below a safe height or be unable to outclimb rising terrain after take-off more than 900 m past the runway end.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Civil Aviation Safety Authority
Safety issue title
Sample operations manual
Safety Issue Description

The CASA sample operations manual used by the operator that allowed any aerodrome in the Enroute Supplement Australia to be used for flight training did not assure that these aerodromes were suitable for use.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Network Aviation
Safety issue title
Risk management
Safety Issue Description

Network Aviation did not include the threat of unforecast weather below landing minima in their controlled flight into terrain risk assessments. This increased the risk that controls required to manage this threat would not be developed, monitored, and reviewed at a management level.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Network Aviation
Safety issue title
Diversion procedure
Safety Issue Description

Network Aviation did not provide their flight crew with a diversion decision-making procedure for the circumstances where their flights encountered unforecast weather below landing minima. This increased the risk that their flight crew would not anticipate and be adequately prepared for a diversion.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport