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

Airwork provided advice of proactive safety action to immediately cease the unauthorised practice and also improve its processes and documentation to prevent a reoccurrence. In conjunction with its other proactive safety actions, the ATSB considers this will be sufficient to address the safety issue.

Proactive action
Action number
Airwork Flight Operations Limited
Action Status
Action description

Airwork advised that:

  • Safety Alert Notice #90, ’Use of Non-Standard Procedures’, was issued to engineering staff to remind them that un-approved procedures were not to be used at any time. Any operation of equipment or changes in configuration were only to be carried out in accordance with approved data. The issue was raised and discussed during ’Tool Box’ sessions and a safety culture roadshow for safety behaviour change was to be created and shared with all staff.
  • Notice to Pilots # 655, ’Cargo Modifications’, was issued to all flight crew. This notice highlighted the concerns related to the occurrence and the need for crew to be extra diligent in their scans relating to cargo door and fire protection systems.