Date Issue Released
Issue number
Issue Owner
Qantas Airways Limited
Safety issue title
Cabin crew training
Safety Issue Description

Qantas's cabin crew recurrent training did not include any situation whereby a disarmed door would have to be rearmed in an emergency. This increased the likelihood that a door would be opened without the escape slide deployed, reducing the number of available exits.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways Limited
Safety issue title
Evacuation commands
Safety Issue Description

Qantas's cabin crew primary evacuation commands did not include phrases such as 'leave everything behind' and 'jump and slide'; instead, these phrases were optional. Consequently, passengers would generally not receive specific guidance until they reached an exit, which would likely slow down the evacuation.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways Limited
Safety issue title
Passenger safety information
Safety Issue Description

Qantas’s method of briefing passengers provided limited and inconsistent information about how to use the escape slides safely and what to do with cabin baggage in an emergency.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Heli-Aust Whitsundays Pty Limited
Safety issue title
Risk controls associated with pilots identifying fatigue risks associated with insufficient sleep and extended wakefulness
Safety Issue Description

The sleep log tool used by the operator contained a coding error and it also pre-loaded sleep periods of future nights by default. This combination of factors reduced the likelihood pilots would identify fatigue risks associated with insufficient sleep and extended wakefulness.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Heli-Aust Whitsundays Pty Limited
Safety issue title
Use of sleep reporting spreadsheet and potential for modification of data input to meet operator’s minimum requirements
Safety Issue Description

The operator's fatigue risk management system relied extensively on a sleep reporting spreadsheet (sleep log) that was based on the prior sleep wake model, and the spreadsheet had a transparent rule set that made the recorded data easy to modify to achieve results that met the operator’s minimum sleep and wake requirements.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Heli-Aust Whitsundays Pty Limited
Safety issue title
Operator’s circuit and approach procedures for marine pilot transfer operations and criteria for achieving a stabilised approach
Safety Issue Description

The operator’s circuit and approach procedures for marine pilot transfer operations did not minimise pilot workload or provide the recommended stabilised approach criteria with mandatory go-around policy. These procedures could allow a combination of conditions that increased the risk of a sustained abnormal flight path and collision with terrain/water.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Heli-Aust Whitsundays Pty Limited
Safety issue title
Operator’s training and assessing procedures for marine pilot transfer operations in degraded visual cueing environments
Safety Issue Description

The operator's training and assessing procedures for marine pilot transfer operations did not provide assurance that pilot under supervision experience, helicopter instrumentation, and instructor capability were suitable for line training at night in a degraded visual cueing environment.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Heli-Aust Whitsundays Pty Limited
Safety issue title
Configuration of instrument panel for instructor or training/check pilot in degraded visual cueing environments
Safety Issue Description

The instrument panels fitted to VH-ZGA and the operator's other EC135 helicopter at Port Hedland were equipped for single-pilot operation under the instrument flight rules. When used for flight training or checking in a degraded visual cueing environment, this configuration has a detrimental effect on the ability of an instructor or training/check pilot to monitor the helicopter's flight path and take over control if required.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Alliance Airlines Pty Limited
Safety issue title
Organisational change
Safety Issue Description

Changes in the operator's key safety post holder positions, safety reporting systems and internal processes reduced effective safety assurance.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Alliance Airlines Pty Limited
Safety issue title
Flight crew training
Safety Issue Description

The operator’s training for the Fokker F28-Mk0100 did not prepare pilots for alpha mode activation during critical phases of flight.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Alliance Airlines Pty Limited
Safety issue title
Safety management reporting system
Safety Issue Description

The operator’s safety management reporting system did not enable the effective prioritisation of submitted safety reports.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Babcock Mission Critical Services Australia
Safety issue title
Inadequate traffic alert and collision avoidance training
Safety Issue Description

The helicopter operator's traffic alert and collision avoidance system knowledge was inadequate with respect to resolution advisory alert terrain considerations and the required intensity of response manoeuvring.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Helicorp Pty Ltd
Safety issue title
External aircraft 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., This delayed the identification and recovery from the unsafe aircraft state resulting in the pilot not identifying the developing rate of descent during the incident, delaying the recovery from the descent.

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
ERSA procedure
Safety Issue Description

The En-Route Supplement Australia included a requirement to add 1,000 ft to the prescribed practice instrument approach ‘altitude’ at Mangalore Airport. The procedure did not detail whether this height was to be applied to the minimum descent altitude or to all approach altitudes, resulting in varied application and an increased risk of traffic conflicts. (Safety issue).

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
Ballina airport safety review
Safety Issue Description

The Civil Aviation Safety Authority review of the airspace surrounding Ballina Byron Gateway Airport did not include data for aircraft transiting the airspace without using the airport. Therefore, the risk associated with occurrences such as this one were not specifically considered when assessing the appropriate airspace classification.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Lufthansa Systems
Safety issue title
Lido airport operational information
Safety Issue Description

The Lido airport operational information did not include the Australian Aeronautical Information Publication (AIP) advice to fit pitot probe covers at Brisbane Airport (related to significant mud wasp activity), as well as other safety AIP information.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Malaysia Airlines
Safety issue title
Change and risk management processes
Safety Issue Description

Malaysia Airlines’ processes for the management of change did not follow recommended industry practices, and its risk and change management processes were not detailed and clear enough to assure:

  • the appropriate level of involvement of subject matter expertise and safety groups
  • that risk controls were implemented and monitored.
Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Malaysia Airlines
Safety issue title
Guidance about the use of pitot covers
Safety Issue Description

Malaysia Airlines did not develop and disseminate guidance and procedures about the use of pitot probe covers to flight crews and engineers, and there was limited awareness among those groups of the need for pitot probe covers at Brisbane Airport.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Malaysia Airlines
Safety issue title
Interim engineering arrangements
Safety Issue Description

Malaysia Airlines did not clearly specify the division of engineering responsibilities between Malaysia Airlines and Aircraft Maintenance Services Australia engineers at Brisbane, leading to ambiguity with regard to who should conduct the final walk-around portion of the transit check. This risk was increased by the operator commencing and continuing flights to Brisbane with interim ground handling and engineering arrangements that varied from

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Malaysia Airlines
Safety issue title
Malaysia Airlines inconsistent walk-arounds
Safety Issue Description

Malaysia Airlines flight crew and engineers did not fully complete the required aircraft inspections.

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