Date Issue Released
Issue number
Issue Owner
Civil Aviation Safety Authority
Safety issue title
Maintenance for repetitve lift missions
Safety Issue Description

The scheduled maintenance requirements for ex-military UH-1 series helicopters may not adequately address the increased risk of fatigue failures associated with repetitive heavy lifting operations that were not considered in the original design fatigue calculations.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Qantas Airways
Safety issue title
Correlation between flight data and incident reports
Safety Issue Description

There was no correlation between the results of the operator’s Flight Operational Quality Assurance and Air Safety Incident Report investigations.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways
Safety issue title
Inconsistent monitoring messages in company documentation
Safety Issue Description

The conflicting requirements and definitions in the operator’s publications in relation to the pilot not flying role had the potential to diminish the importance of monitoring as an essential element in an aircraft’s safe operation.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Qantas Airways
Safety issue title
Monitoring of landing gear through Flight Operational Quality Assurance
Safety Issue Description

There were no soft and hard triggers in the operator’s Flight Operational Quality Assurance system to monitor the selection of the aircraft’s landing gear during an approach.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Airbus Industrie
Safety issue title
Windshield terminal block failure
Safety Issue Description

Windshields manufactured with terminal block fittings containing polysulfide sealant (PR1829) have been shown to be predisposed to premature overheating failure that could lead to the development of a localised fire.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Raytheon Aircraft Co
Safety issue title
Cabin Altitude Warning switc wiring diagram
Safety Issue Description

The cabin altitude warning pressure switch maintenance manual wiring diagram did not provide a clear indication of the wiring connections for the superseded switch.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Raytheon Aircraft Co
Safety issue title
Replacement of cabin altitude warning switch
Safety Issue Description

The aircraft maintenance manuals did not include the operating specifications of the replacement cabin altitude warning pressure switch hampering the required verification of switch serviceabilty.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Civil Aviation Safety Authority
Safety issue title
Emergency Locator Transmitter re-programming risk
Safety Issue Description

There were only subtle cues to the fitment of programming dongles and no requirement to test Emergency Locator Transmitter (ELT) programming after installation, increasing the risk of inadvertent and undetected ELT re-programming and a less effective search and rescue response.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
CFM International
Safety issue title
Turbine blade material susceptible to creep rupture
Safety Issue Description

Material characteristics of some the LPT blades installed in engine 858322 were consistent with a raw material manufacturing cast that had previously been identified as being susceptible to creep rupture

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
James Technologies (Aviation) Pty Ltd
Safety issue title
Independent fuel check procedures
Safety Issue Description

The operator did not have a procedure in place to ensure independent cross-checking of the helicopter's fuel quantity.

Issue Status
No longer relevant
Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Airservices Australia
Safety issue title
Compromised separation training
Safety Issue Description

The controller had not received training in compromised separation recovery techniques.

Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Airservices Australia
Safety issue title
Ambiguity in documentation
Safety Issue Description

Ambiguity existed between the Manual of Air Traffic Services and the Aeronautical Information Publication in relation to the assignment of non-standard cruising levels and the definition of an ‘operational requirement’.

Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Airservices Australia
Safety issue title
Airspace design for strategic separation
Safety Issue Description

Moorabbin GAAP airspace design did not assure lateral or vertical strategic separation between traffic flows. This increased the risk of a mid-air collision.

Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Airservices Australia
Safety issue title
Action related to review of GAAP operations
Safety Issue Description

There was no evidence of any action taken by Airservices to address safety recommendations related to a review of Key Performance Indicators (KPI’s) of GAAP operations.

Date issue released
Mode of Transport
Aviation
Transport Function
Airspace
Issue number
Issue Owner
Jetstar Airways
Safety issue title
Quarantine procedures
Safety Issue Description

There was no procedure or guidance for the segregation of freight that was rejected during loading.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Jetstar Airways
Safety issue title
Ground handling emergency communication procedures
Safety Issue Description

The aircraft operator did not provide procedures that allowed ground handling personnel to communicate effectively with the flight crew in the event of an urgent operational matter occurring after pushback.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Airtex Air Services Pty Ltd
Safety issue title
Endorsement training
Safety Issue Description

The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual , with the result that the pilot’s competence and ultimately, safety of the operation could not be assured.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
National Parks and Wildlife Service
Safety issue title
Low visibility risk at helicopter landing area
Safety Issue Description

The helicopter landing area was occasionally subjected to rapidly-moving fog or low cloud that increased the risk of flights under the visual flight rules encountering instrument meteorological conditions.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Helicopter owner
Safety issue title
Cargo door seal exceeds flushness tolerance
Safety Issue Description

Installation of new cargo door seals resulted in the cargo door being held outside of the flushness requirement specified in the aircraft maintenance manual

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Department of Infrastructure, Transport, Regional Development and Local Government
Safety issue title
Wind Modelling Criteria
Safety Issue Description

There were no criteria for assessing the potential wind impact of aerodrome building developments on aircraft operations.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other