Date Issue Released
Issue number
Safety issue title
Cessna 206 emergency procedures
Safety Issue Description

The Cessna 206 procedure for ditching and forced landing states that the flaps are to be extended to 40°. While that permits the aircraft to land at a slower speed, it also significantly restricts emergency egress via the cargo door. However, there is no warning about that aspect in the ditching or forced landing pilot’s operating handbook emergency procedures.

Issue Owner
Textron Aviation
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
Cabin exit design criteria (Issue owner: Civil Aviation Safety Authority)
Safety Issue Description

Cessna 206 aircraft that feature a rear double cargo door do not meet the aircraft certification basis for the design of cabin exits. Wing flap extensions beyond 10° will block the forward portion of the rear double cargo door, significantly hampering emergency egress. This has previously resulted in fatalities.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Not addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Maintenance manual supplement
Safety Issue Description

The inspection procedures in the West Star Aviation maintenance manual supplement for extended life program Cessna 441 aircraft were inadequate to detect the progressive disbonding of the emergency exit door.

Issue Owner
West Star Aviation
Transport Function
Aviation: Maintenance
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator consolidation processes for flight crew
Safety Issue Description

Although the operator complied with the regulatory requirements for training and experience of pilots, it had limited processes in place to ensure pilots with minimal time and experience on a new and technically different helicopter type had the opportunity to effectively consolidate their skills on the type required for conducting the operator's normal operations to pontoons.

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Pilots leaving the controls of the helicopter
Safety Issue Description

It was common practice for the operator’s pilots to leave the controls of their helicopter, while the rotors were turning and the friction locks applied, to escort passengers to and from the helicopter.

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator management of birdstrikes
Safety Issue Description

There was often a significant number of birds located on the pontoons at Hardy Reef used by the operator. However, the operator did not have a process to systematically manage the risk of birdstrike. For example:

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Operator helicopter loading practices
Safety Issue Description

Although the operator had calibrated scales available for use at two of their check-in locations, they were not routinely used to ascertain actual passenger and/or baggage weights. Instead, the operator's personnel relied on passengers’ volunteered weights (without an additional allowance) and only weighed passengers when the volunteered weights were perceived to be inaccurate.

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Passengers with reduced mobility
Safety Issue Description

The operator’s system used to identify passengers with reduced mobility and/or required additional safety briefing information relied on passengers self-reporting a problem.

Issue Owner
Whitsunday Air Services
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Design of the EC120B rear left emergency exit
Safety Issue Description

Due to multiple factors, the design of the rear left sliding door (emergency exit) on the EC120B helicopter was not simple and obvious to use unless the occupant was provided with specific instructions about how to operate the exit. In particular:

  • the door required three actions to open (pull handle up, push door out, slide door back), and the second action was not indicated in either the design of the handle or the placard next to the handle
  • the design of the inside handle was such that its purpose may not have been readily apparent to many users.
Issue Owner
Airbus Helicopters
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Partially addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Requirements for verbally briefing passengers on emergency exits
Safety Issue Description

There was no requirement for operators of passenger transport flights in aircraft with six or less seats to provide passengers with a verbal briefing, or written briefing material, on the method for operating the emergency exits.

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
Fuel quantity assessment methods
Safety Issue Description

Although the operator had specified multiple methods of cross-checking fuel quantity gauge indications for its C441 fleet, there were limitations in the design, definition and/or application of these methods. These included:

Issue Owner
Skippers Aviation
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Maintenance processes for landing gear
Safety Issue Description

The operator did not place appropriate emphasis on ensuring the continuing airworthiness of the landing gear of its GA8 fleet, although being aware of:

  • the increased loads on the landing gear when routinely operating from beach landing areas up to 20–30 times daily, and being subjected to a salt-laden and humid environment
  • the axle failure of VH-BFS in 2009
  • the mandatory inspection requirements of service bulletin SB-GA8-2016-169.
Issue Owner
Air Fraser Island
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Aeropower post-training supervision
Safety Issue Description

There were no requirements in Aeropower procedures to provide any post-training supervision for powerline operations. What supervision was provided was ineffective in identifying that a modified stringing method was being used by the pilot.

Issue Owner
Aeropower Pty. Ltd.
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Crew risk awareness
Safety Issue Description

Although required by the harness instrument commonly issued by the Civil Aviation Safety Authority, the operator did not appraise shooting crews of the risks of using only a harness for restraint during low-level flight.

Issue Owner
Jayrow Helicopters
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Harness instrument clarity
Safety Issue Description

A harness instrument, commonly issued by the Civil Aviation Safety Authority (CASA), stated that a harness could be used instead of a seatbelt for take-off and landing. Although not intended by CASA, this instrument was easily able to be misinterpreted as indicating that a seatbelt was not required to be used during take-off and landing.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Aerial platform shooter emergency training
Safety Issue Description

Recurrency training and drills in aircraft emergencies were not required for reissue of an aerial platform shooting permission. Some shooters last conducted training about 20 years prior, during initial issue of their permissions.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
The Director of National Parks' risk management
Safety Issue Description

The Director of National Parks did not actively manage the risk of the aerial culling task being conducted in the Kakadu National Park, or effectively supervise the operation. As a result, an increase in the number of crew, a change in helicopter type and change of helicopter operator all progressed without requisite risk management. This exposed crew to avoidable harm during low-level aerial shooting operations.

Issue Owner
Director of National Parks
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Helmet provision and use
Safety Issue Description

Although the Director of National Parks’ safe operating procedures required shooters and spotters to wear helmets during aerial culling tasks, helmets were not provided or used on a routine basis.

Issue Owner
Aviation: General aviation
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Adequately addressed
Mode of Transport
Aviation
Issue number
Safety issue title
Fitment of recording devices in light aircraft - International Civil Aviation Organization
Safety Issue Description

Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in important safety issues not being identified, which may remain a hazard to current and future passenger carrying operations.

The ATSB is issuing the following recommendation: 

Issue Owner
International Civil Aviation Organization
Transport Function
Aviation: Air transport
Date issue released
Issue Status
Open – Safety action pending
Mode of Transport
Aviation
Issue number
Safety issue title
No regulatory requirement for carbon monoxide detectors
Safety Issue Description

There was no regulatory requirement from the Civil Aviation Safety Authority for piston‑engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin.

Issue Owner
Civil Aviation Safety Authority
Transport Function
Aviation: General aviation
Date issue released
Issue Status
Closed – Not addressed
Mode of Transport
Aviation