Date Issue Released
Issue number
Issue Owner
Fokker Services
Safety issue title
Maintenance Publications
Safety Issue Description

While the manufacturer's instructions for the zonal inspections detailed that installation blankets could be removed 'as necessary', they did not reference the insulation blanket installation procedure. This resulted in insulation blankets not being secured to the structure.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
United States Federal Aviation Administration
Safety issue title
Compressor turbine blade failure
Safety Issue Description

Pratt & Whitney Canada (PWC) PT6A-114A engines fitted with compressor turbine vane rings that have been repaired in accordance with the United States Federal Aviation Administration‑approved scheme STI 72-50-254 have a significantly increased likelihood of CMSX-6 compressor turbine blade fracture and subsequent failure of the engine compared to those engines fitted with PWC‑manufactured compressor turbine vane rings.

Issue Status
Open – Safety action pending
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Virgin Australia Airlines
Safety issue title
Runway verification cues
Safety Issue Description

Virgin Australia Airlines did not require flight crew to confirm and verbalise external cues such as runway signs, markings, and lights to verify an aircraft’s position was correct prior to entering and lining up on the runway.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Virgin Australia Airlines
Safety issue title
Timing of 'before take-off' procedure
Safety Issue Description

Virgin Australia Airlines did not require ATR flight crews to complete the Before take-off procedure prior to reporting ‘ready’ to air traffic control. This increased the risk of flight crews completing this procedure while entering the runway, diverting their attention to checklist items at a time when monitoring and verifying was critical.

Issue Status
No longer relevant
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Robinson Helicopter Company
Safety issue title
Pilot’s operating handbook
Safety Issue Description

The Robinson R44 pilot’s operating handbook low rotor RPM recovery procedure did not include reference to the minimum power airspeed for the helicopter as a consideration, which may assist a pilot to recover from a low rotor RPM condition. [Safety Issue]

Issue Status
Closed – Not addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Professional Helicopter Services
Safety issue title
Passenger scales
Safety Issue Description

Professional Helicopter Services did not have a calibration schedule for their passenger scales, which were under-reading. This increased the risk of their helicopters not achieving their expected take-off performance.

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
Inhibition of safety alerts for combined air traffic control roles
Safety Issue Description

Airservices Australia’s configuration of the integrated tower automation suite (INTAS) at Perth Airport had resulted in a situation where controllers performing some combined roles had the INTAS aural and visual alerts inhibited at their workstation. As a result, controllers performing such combined roles would not receive a stop bar violation alert or runway incursion alert at their workstation.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Perth Airport Pty Ltd
Safety issue title
Location and design of taxiway J2 at Perth Airport
Safety Issue Description

The location and design of taxiway J2 at Perth Airport significantly increased the risk of a runway incursion on runway 06/24 for aircraft landing on runway 03. Taxiway J2 was published as the preferred exit taxiway for jet aircraft and, although mitigation controls were in place, they were not sufficient to effectively reduce the risk of a runway incursion.  

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways
Safety issue title
Operator guidance for flight crew briefing of aerodrome hot spots
Safety Issue Description

Although Qantas provided detailed guidance to flight crews about the content of departure and approach briefings, it did not specifically require aerodrome hot spots to be briefed.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Pratt & Whitney Canada
Safety issue title
Unclear procedures in Aircraft Maintenance Manual
Safety Issue Description

The procedures in the aircraft maintenance manual relating to chip detector debris analysis were written in a way that could cause confusion and error. This probably influenced the actions of the maintenance personnel to release the aircraft to service with a deteriorating bearing.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Pratt & Whitney Canada
Safety issue title
Power turbine shaft corrosion
Safety Issue Description

The power turbine shaft in Pratt & Whitney Canada PW100 series engines operating in certain marine environments is susceptible to corrosion pitting, which can grow undetected between scheduled inspections. This increases the risk of shaft fracture resulting in engine failure.

Issue Status
Closed – Partially addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Civil Aviation Safety Authority
Safety issue title
Balloon visual meteorological conditions
Safety Issue Description

The visual flight rules permitted balloons to arrive and depart in foggy conditions without assurance that sufficient visibility existed to see and avoid obstacles.

Issue Status
Closed – Not addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Cloncurry Air Maintenance
Safety issue title
Maintenance practices
Safety Issue Description

Cloncurry Air Maintenance had adopted a number of practices, which included using abbreviated inspection checklists, not recording all flight control disturbances and not progressively certifying for every inspection item as the work was completed, which increased the risk of memory-related errors and the omission of tasks.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Rolls-Royce plc
Safety issue title
Inspection period for blade cracking
Safety Issue Description

The scheduled inspections recommended by Rolls-Royce to detect cracking in Trent 700 fan blades, were insufficient to detect early onset fatigue cracks in the membrane to panel bond before those cracks could progress to failure.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Rolls-Royce plc
Safety issue title
Fatigue cracking of Trent 700 fan blades
Safety Issue Description

The Trent 700 blade manufacturing process produced a variation in internal membrane-to-panel acute corner geometry that, in combination with the inherent high level of blade panel stress, could lead to increased localised stresses in those corner areas and the initiation and propagation of fatigue cracking.

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
Guidance on vehicle-assisted deflation risks
Safety Issue Description

The Civil Aviation Safety Authority provided no guidance for operators concerning the risks associated with vehicle‑assisted deflation.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Picture This Ballooning
Safety issue title
Risk management processes
Safety Issue Description

Picture This Ballooning's safety risk management processes and practices were not sufficient to facilitate the identification of key operational risks associated with vehicle-assisted deflation.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Picture This Ballooning
Safety issue title
Vehicle-assisted deflation procedures
Safety Issue Description

Picture This Ballooning did not have any procedures for conducting vehicle-assisted deflation.

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Pilatus Aircraft Ltd
Safety issue title
Pilatus PC-12 trim and flap interrupt switches
Safety Issue Description

The similarities between the Trim Interrupt and Flap Interrupt switches and the proximal location of the two switches unnecessarily increased the risk of mis-selection and contributed to the excessive out-of-trim condition.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Cicaré S.A.
Safety issue title
Cicaré S.A. CH-7T/B/BT service bulletin
Safety Issue Description

The Cicaré 7T/B/BT mandatory service bulletin (BSC007) for the general stabiliser support assembly provided limited guidance for disassembly of the manufactured component and did not stipulate a compliance period within which to perform the inspection nor provide consideration for repeat inspections. This potentially reduced the opportunity to detect the presence of crack initiation and growth in the stabiliser support assembly.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation