Date Issue Released
Output Number
Title
MO-2009-009-SAN-021
Organisation
American Bureau of Shipping
Date released
Approval Date
Status
Closed
Recommendation type
Output Number
Organisation
US Federal Aviation Administration
Date released
Approval Date
Status
Closed - Partial Action
Recommendation type
Output Number
Organisation
Operators and flight crews of transport category aircraft
Date released
Approval Date
Status
Closed
Recommendation type
Output Number
Organisation
Boeing Company
Date released
Approval Date
Status
Closed - Action Taken
Recommendation type
Issue number
Issue Owner
Boeing Co
Safety issue title
Flight crew quick reference handbook
Safety Issue Description

The operator’s flight crew quick reference handbook did not include sufficient information for flight crew to manage the emergency.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways
Safety issue title
Maintenance processes for galley floor sealing
Safety Issue Description

Maintenance processes did not identify or correct the deterioration of the galley floor sealing

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Boeing Co
Safety issue title
Maintenance processes did not identify or correct the deterioration of the dripshield
Safety Issue Description

Maintenance processes did not identify or correct the deterioration of the drip shield.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Helifarm Pty Ltd
Safety issue title
Hazard identification procedures
Safety Issue Description

The Aerial Agricultural Association of Australia suggestion that an additional hazard identification check be carried out prior to a cleanup run was not routinely practiced by the pilots, or monitored by the operator.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Qantas Airways
Safety issue title
Operator’s documented design objectives
Safety Issue Description

The aircraft operator’s documented design objectives did not explicitly require the protection of non-structural systems from liquid contact or ingress.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Boeing Co
Safety issue title
Floor sealing design
Safety Issue Description

The location of the decompression panel and absence of cabin floor sealing above the main equipment centre increased the risk of liquid ingress into the aircraft’s electrical systems.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Boeing Co
Safety issue title
Maintenance processes for drain line heater
Safety Issue Description

Maintenance processes did not identify or correct the inoperability of the forward drain line heater.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Hamilton Sundstrand Corporation
Safety issue title
Maintenance processes for corrosion in the generator control units
Safety Issue Description

Maintenance processes did not identify or correct the corrosion in the generator control units.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Boeing Co
Safety issue title
Battery discharge message priority design
Safety Issue Description

The priority level of the battery discharge messages that were provided by the engine indicating and crew alerting system did not accurately reflect the risk presented by the battery discharge status.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Qantas Airways
Safety issue title
Maintenance for drain lines
Safety Issue Description

The galley drain operation and maintenance processes did not adequately prevent blockage and overflow of the aircraft’s drain lines.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Helifarm Pty Ltd
Safety issue title
Potential to overload helicopter
Safety Issue Description

The removal of fluid quantity markings from, and unapproved modifications to the helicopter’s spray tank by the operator increased the risk of overweight operations

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Boeing Company
Safety issue title
Design of galley floor sealing
Safety Issue Description

The floor sealing around the forward galley was not of sufficient extent to prevent liquids from passing through to the under floor area.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
US Federal Aviation Administration
Safety issue title
Fluid protection design guidance
Safety Issue Description

The United States Federal Aviation Administration regulations and associated guidance material did not fully address the potential harm to flight safety posed by liquid contamination of electrical system units in transport category aircraft.

 

Issue Status
Closed – Adequately addressed
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Aeropower Pty. Ltd.
Safety issue title
Appreciation of the significance of transpositions
Safety Issue Description

Neither the maintenance provider, nor the helicopter operator appreciated the potential significance of mid-span transposition information to the joint testing task.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Aeropower Pty. Ltd.
Safety issue title
Checklist for joint testing
Safety Issue Description

The operator's joint testing procedures were not comprehensive with respect to hazard identification and the use of standard phraseology.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
The helicopter owner
Safety issue title
Supervision
Safety Issue Description

There was no direct supervision of the joint testing operations.

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