Date Issue Released
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
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
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
Canberra Airport Operator
Safety issue title
Buildings dimensions and location
Safety Issue Description

Two buildings were constructed north of the runway 12 threshold at a height and position that could generate turbulence affecting the approach, threshold and touchdown areas of the runway under some wind conditions.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Airports
Issue number
Issue Owner
Canberra Airport Pty Ltd
Safety issue title
Airport Wind Modelling during building development
Safety Issue Description

The limited consideration of the potential wind impact of the two buildings to the north of runway 12 during northerly wind conditions has resulted in continued operations to that runway in those conditions without any alert to affected pilots about the associated risk.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Airports
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
Issue number
Issue Owner
QantasLink
Safety issue title
Take-off procedures
Safety Issue Description

The operator did not have procedures to assist the crew to ensure that the aircraft was lined up on the runway centreline in preparation for takeoff.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Boeing Training and Flight Services
Safety issue title
Third party access to Airbus
Safety Issue Description

When revising or maintaining its A320 endorsement training program, the third party training provider did not use or have access to current versions of the aircraft manufacturer’s recommended training program.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
European Aviation Safety Agency
Safety issue title
Pitot probe design specifications
Safety Issue Description

Although the pitot probes fitted to A330/A340 aircraft met relevant design specifications, these specifications were not sufficient to prevent the probes from being obstructed with ice during some types of environmental conditions that the aircraft could encounter.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Jetstar Airways
Safety issue title
Unreliable airspeed training
Safety Issue Description

By the time of the 28 October 2009 occurrence, many of the operator’s A330 flight crew had not received unreliable airspeed training. Such training started being introduced in the operator’s recurrent training program before the occurrence.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Air transport
Issue number
Issue Owner
Australian Helicopters Pty Ltd
Safety issue title
Lack of formal task risk management
Safety Issue Description

There was no formal risk assessment process in use at the operator’s Horn Island base.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Honeywell
Safety issue title
Landing gear wheel design
Safety Issue Description

The post-2005 main landing gear wheel design had shown a susceptibility to fatigue cracking at the inner hub bearing bore shoulder radius.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: Other
Issue number
Issue Owner
Honeywell
Safety issue title
Inadequate inspection procedures
Safety Issue Description

At the time of the last tyre change, crack initiation at the bearing bore shoulder radius was an emerging issue with no requirement for mandatory inspection of this area during a tyre change.

Date issue released
Mode of Transport
Aviation
Transport Function
Aircraft Maintenance
Issue number
Issue Owner
Australian Helicopters Pty Ltd
Safety issue title
Requirement to confirm hover reference
Safety Issue Description

The operator’s winching procedure did not include the requirement to confirm adequate hover reference existed overhead an intended winch area prior to deploying personnel on the winch.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Airtourer Association
Safety issue title
Fuel dipstick methods
Safety Issue Description

There was the potential for the incorrect use of the dipstick to result in the over-reading of the fuel quantity.

Date issue released
Mode of Transport
Aviation
Transport Function
Aviation: General aviation
Issue number
Issue Owner
Airtourer Association
Safety issue title
Aircraft's pilot operating handbook
Safety Issue Description

Information contained in the approved flight manual and pilot's operating handbook was not applicable to the engine that was fitted to the aircraft.

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