Safety issue

Status

Status justification

AO-2015-089: In-flight break-up involving Cicaré S.A. CH-7BT helicopter, VH-JEW, near Roy Hill Station, Western Australia, on 28 July 2015

AO-2015-089-SI-01: 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.

Closed-Adequately addressed

The ATSB is satisfied that, with the inclusion of BSC007 in the maintenance manual and a clear direction to inspect the stabiliser assembly every 100 hours, cracking in this location will likely be identified prior to failure. Additionally, Cicaré have redesigned the component, and all new Cicaré 7 series helicopters will be fitted with the new design, which is also available for retrofit on earlier helicopters.

Safety issue

Status

Status justification

AO-2017-005: Collision with terrain following an engine power loss involving Cessna 172M, VH-WTQ, 12 NM (22 km) north-west of Agnes Water, Queensland on 10 January 2017

AO-2017-005-SI-01: The operator normally conducted airborne inspections of the Middle Island aeroplane landing area at about 50–100 ft while flying at normal cruise speed towards an area of water, and its procedures did not ensure the effective management of the risk of an engine failure or power loss when at a low height.

Closed-No longer relevant

Following the accident, the operator ceased flight operations.

AO-2017-005-SI-02: Although the operator’s procedures required that actual weights be used for passengers, baggage and other cargo, this procedure was routinely not followed, and pilots relied on estimated weights when calculating an aircraft’s weight and balance.

Closed-No longer relevant

Following the accident, the operator ceased flight operations.

AO-2017-005-SI-03: Although the operator’s procedures required that baggage and cargo be secured during flight, this procedure was routinely not followed, and the aircraft were not equipped with cargo nets or other means for securing loads in the baggage compartment.

Closed-No longer relevant

Following the accident, the operator ceased flight operations.

AO-2017-005-SI-04: The operator’s pilots routinely conducted near-aerobatic manoeuvres during passenger charter flights. However, procedures for these manoeuvres were not specified in the operator’s Operations Manual, and there were limited controls in place to manage the risk of these manoeuvres.

Closed-No longer relevant

Following the accident, the operator ceased flight operations.

AO-2017-005-SI-05: There were a significant number and variety of problems associated with the operator’s activities that increased safety risk, and the operator’s chief pilot held all the key positions within the operator’s organisation and conducted most of the operator’s flights. Overall, there were no effective mechanisms in place to regularly and independently review the suitability of the operator’s activities, which enabled flight operations to deviate from relevant standards.

Closed-No longer relevant

Following the accident, the operator ceased flight operations. Some of the regulatory changes being introduced under Civil Aviation Safety Regulation (CASR) Part 119 and Part 135 may also help address these types of issues in some small passenger transport operators (see Additional safety action).

AO-2017-005-SI-06: Upper torso restraints (UTRs) were not required for all passenger seats for small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992, including for passenger transport operations. Although options for retrofitting UTRs are available for many models of small aircraft, many of these aircraft manufactured before the applicable dates that are being used for passenger transport have not yet been retrofitted.

Closed-Not addressed

No changes in mandatory requirements for upper torso restraints have occurred, even for air transport operations involving small aircraft for which mandatory service bulletins exist.

AO-2017-005-SI-07: There was no requirement for operators of passenger transport flights in aircraft with six or less seats to provide passengers with a verbal briefing, or written briefing material, on the brace position for an emergency landing or ditching, even for aircraft without upper torso restraints fitted to all passenger seats.

Safety action still pending

AO-2017-005-SI-08: The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Closed-Adequately addressed

The ATSB is satisfied that the changes introduced by CASA, if consistently implemented, will reduce the risk of this safety issue.

Safety issue

Status

Status justification

AO-2017-013: Collision with water involving Grumman American Aviation Corp G-73, VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017

AO-2017-013-SI-01: The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors: * While the Air Display Manual provided guidance to organisers conducting an air display, it did not inherently provide the processes and tools needed for CASA to approve and oversee one and no other documented guidance existed. * Unlike the accreditation models adopted by some other countries, CASA did not have a systematic approach for assessing the suitability of those responsible for organising, coordinating and participating in air displays * CASA did not have a structured process to ensure that risks were both identified and adequately treated. The combination of these factors significantly increased the likelihood that safety risks associated with the conduct of the air display were not adequately managed.

Safety action still pending

Safety issue

Status

Status justification

AO-2017-066: Engine failure involving Airbus A330, 9M-XXE, near Carnarvon, Western Australia, on 25 June 2017

AO-2017-066-SI-01: 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.

Closed-Adequately addressed

While Roll-Royce are continuing to work on gaining an understanding of the manufacturing processes that may influence the acute corner radius, the ATSB is satisfied that the blade improvements are sufficient on their own to reduce the likelihood of further fatigue crack initiation in Trent 700 fan blades.

AO-2017-066-SI-02: 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.

Closed-Adequately addressed

The likelihood of further fan blade failures has been reduced due to the actions taken by the engine manufacturer, including the enhanced inspection technique with smaller intervals, and the removal of the blades that have an increased probability of failure through stress induced cracking.

Safety issue

Status

Status justification

AO-2017-069: Collision with terrain involving SOCATA TB-10 Tobago, VH-YTM, near Mount Gambier Airport, South Australia, on 28 June 2017

AO-2017-069-SI-01: Angel Flight did not consider the safety benefits of commercial passenger flights when suitable flights were available.

Safety action still pending

AO-2017-069-SI-02: Angel Flight had insufficient controls in place, and provided inadequate guidance to pilots to address the additional operational risks associated with community service flights.

Safety action still pending

AO-2017-069-SI-03: There were limited opportunities for Angel Flight to be made aware of any safety related information involving flights conducted on its behalf.

Closed-Adequately addressed

The combination of the requirement implemented by Angel Flight Australia for pilots to report safety occurrences to the organisation in addition to normal ATSB reporting requirements, and the ongoing introduction of community service flight activity type in BITRE activity and ATSB occurrence databases, will increase the availability of safety information in the community service flight sector.

AO-2017-069-SI-04: The Civil Aviation Safety Authority did not have a system to differentiate between community service flights and other private operations, which limited its ability to identify risks. This hindered the Civil Aviation Safety Authority's ability to manage risks associated with community service flights.

Closed-Adequately addressed

The ATSB notes that through the legislative instrument that came into force in March 2019, CASA now has a system to differentiate between community service flights and other private operations. This will allow CASA to conduct ongoing identification and monitoring of risks associated with community service flights to be able to it to manage and control those risks.

Safety issue

Status

Status justification

AO-2017-098: Pressurisation event involving Airbus A320, PK-AXD, 160 NM (300 km) north of Perth, Western Australia, on 15 October 2017

AO-2017-098-SI-01: The pre-flight safety briefing and safety information card did not include a clear instruction on how to activate the flow of oxygen from the passenger oxygen masks and that the bag may not inflate when oxygen is flowing. This resulted in some passengers not understanding whether or not there was oxygen flowing in the mask.

Closed-Adequately addressed

AirAsia Indonesia have implemented changes in accordance with the safety issue raised by the ATSB. This included amending its passenger safety briefing cards and passenger announcement to include the instruction that if oxygen masks deploy the passengers must pull down on them firmly, and that the oxygen mask bags may not inflate during use. The action taken is considered to adequately address the safety issue.

Safety issue

Status

Status justification

AO-2018-007: Engine failure involving Airbus Industrie A330-323, registered 9M-MTM, 37 km north of Curtin Airfield, Western Australia on 18 January 2018

AO-2018-007-SI-01: There were a total of 16 engine malfunction events globally over a 4-year period attributed to modification of the Advantage 70™ engine. The modification increased the engine outer duct gas path temperature, which led to distortion and liberation of the outer transition duct segments.

Safety action still pending

Safety issue

Status

Status justification

AO-2018-025: Runway excursion and collision with terrain involving Van's RV-6A, VH-OAJ, Somersby, New South Wales, on 18 March 2018

AO-2018-025-SI-01: The Civil Aviation Advisory Publication for Aeroplane Landing Areas (92-1(1)) did not have guidance for the inclusion of a safe runway overrun area.

Safety action still pending

Safety issue

Status

Status justification

AO-2019-014: Ground handling event involving Kavanagh B-400 Balloon, VH-LNB, near Coldstream, Victoria, on 16 March 2019

AO-2019-014-SI-01: 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.

Closed-Adequately addressed

The ATSB agrees that compliance with the requirements of Part 131 will likely facilitate the identification of key operational risks including those associated with vehicle-assisted deflation. Prior to the introduction of Part 131, the operator’s review of their own safety management processes and practices and an annual, industry-wide review will also likely facilitate the identification of key operational risks.

AO-2019-014-SI-02: Picture This Ballooning did not have any procedures for conducting vehicle-assisted deflation.

Closed-Adequately addressed

The ATSB is satisfied that these procedures should significantly reduce the likelihood of basket tipping and personnel injury when conducting a vehicle-assisted deflation.

AO-2019-014-SI-03: The Civil Aviation Safety Authority provided no guidance for operators concerning the risks associated with vehicle-assisted deflation.

Open-Safety action pending

Safety issue

Status

Status justification

AO-2019-019: Pitch trim runaway and partial loss of control involving Pilatus PC-12/47E, VH-OWJ, near Merredin, Western Australia, on 14 April 2019

AO-2019-019-SI-01: 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.

Closed-Partially addressed

The safety action nominated by Pilatus may result in less need for pilots to use the Trim Interrupt switch (due to more reliable relays) and training guidance may increase the probability of the correct switch being selected in the case of a trim runaway event. However, the two switches do remain identical and co-located, and given the Flap Interrupt switch is no longer required, there is potential for engineering controls to eliminate the mis-selection of the interrupt switches and associated possible loss of control.

Safety issue

Status

Status justification

MO-2017-010: Grounding of the bulk carrier Orient Centaur at Weipa, Queensland on 6 November 2017

MO-2017-010-SI-01: Tugs were to be available to escort the mini cape-size ships until they had entered the South Channel, where they were stood down. However, the tug masters had not been trained in the specifics of escort towage nor in emergency response.

Closed-Adequately addressed

The action taken by training all pilots and tug masters in emergency response and escort towage adequately address the issue.

MO-2017-010-SI-02: In pre-trial simulations, the risks associated with engine failure during departure were only considered up to when a ship had entered the South Channel. Consequently, the tugs were not in attendance to assist if propulsion was lost.

Closed-Adequately addressed

The action taken by mandating the use of an escort tug from the wharf and throughout the South Channel to Beacon SC4, and additional tug availability, should adequately address the issue.

Safety issue

Status

Status justification

MO-2018-001: Serious injury on board Berge Daisetsu, Portland, Victoria, on 11 January 2018

MO-2018-001-SI-01: The fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform the equipment would not have worked correctly, resulting in serious or fatal injuries.

Closed-Adequately addressed

The safety actions taken by Berge Bulk Maritime will significantly reduce the likelihood of a similar future occurrence. The training, equipment and machinery changes implemented and progressing should greatly reduce the likelihood of similar issues with working aloft and appropriate use of PPE in the future.

Safety issue

Status

Status justification

MO-2018-008 344: Loss of containers overboard involving YM Efficiency, 16 NM east-south-east of Newcastle, New South Wales, on 1 June 2018

MO-2018-008-SI-01: The ship's manager's (Yang Ming) cargo-planning process ashore did not ensure that the proposed container stowage plan complied with the stowage and lashing forces requirements of the ship's Cargo Securing Manual. Consequently, compliance with these requirements relied entirely on shipboard checks, made at a late stage, with limited options available for amendments without unduly impacting commercial operations.

Closed-Adequately addressed

The inclusion of lashing forces checks during the shore planning process is a practical means of reducing the risk of unsafe container stowage plans being presented to the ship at a late stage in the container shipping process. Familiarisation and training provided to shore planners should ensure that the outcomes of the lashing forces checks are understood and will allow effective action to be taken at an early stage. This provides assurance that container stowage plans presented to ships are as safe as practically possible.

Safety issue

Status

Status justification

RO-2016-008: Track worker fatally injured when struck by train W510, Clyde, New South Wales, on 18 June 2016

RO-2016-008-SI-01: Sydney Trains’ work-planning process, involving multiple work groups, did not assure the consideration of worksite safety for all tasks undertaken by each involved party over the duration of the work and when returning the rail infrastructure into service.

Closed-Partially addressed

The ATSB is satisfied that once implemented, all maintenance work parties can complete maintenance work in the planned maintenance windows. There remains an opportunity for maintenance work, such as booking points out and back in to occur outside of the planned maintenance windows. However, it remains the responsibility of the Protection Officer to follow the rules and ensure they protect themselves as required.

RO-2016-008-SI-02: The network rules and procedures require communications to be clear, brief and unambiguous. Network communications by various parties in Sydney Trains were not in accordance with the principles underpinning the network rules.

Closed-Adequately addressed

The ATSB is satisfied that this Audio Monitoring System will improve the safety critical communications as it is used to audit network communications for compliance and to identify improvement opportunities.

RO-2016-008-SI-03: The worksite protection method presented an increased risk, in that track workers might inadvertently exit the worksite, and subsequently be in the immediate vicinity of operational main line rail traffic. Sydney Trains network rules and procedures for a Track Occupancy Authority did not manage the increased risk for the chosen worksite protection method.

Closed-Partially addressed

The action taken by Sydney Trains does not make any change to the TOA network rule, however Sydney Trains seeks to address the risk by bolstering other network rules that require the protection officer to plan and deliver worksite protection arrangements.
The more specific instruction decreases ambiguity for the protection officer. Further, the program to improve safety culture, if successful, will provide greater impetus for workers to adhere to the rules.

RO-2016-008-SI-04: The Sydney Trains worksite briefing process did not compel a new work group to seek a worksite protection pre-work briefing when accessing an existing worksite.

Closed-Adequately addressed

The changes in the document NRF014 Worksite Protection Pre-work Briefing make it clear that all workers on a worksite are required to be briefed on both the protection measures and the work to be performed.

Safety issue

Status

Status justification

RO-2017-014: Derailment of grain train 8838N, Narwonah, New South Wales, on 1 October 2017

RO-2017-014-SI-01: There were track defects identified in the vicinity of the derailment site prior to the derailment. The maintenance of defects in this section of track was not successful in preventing the defects from re-occurring.

Closed-Adequately addressed

The safety action addresses the issue at the location of the derailment and changes have been made to address maintenance issues on a more systemic level.

Safety issue

Status

Status justification

RO-2018-004: Collision of Waratah passenger train A42 with buffer stop at Richmond Station, New South Wales, on 22 January 2018

RO-2018-004-SI-01: The crash energy management system on the Waratah passenger train A42 reduced the impact force of the collision but not all components performed as designed. The performance of the crash energy management system was significantly limited by the buffer stop at Richmond being incompatible with the front of the Waratah train.

Closed-Adequately addressed

The ATSB notes that the actions taken to examine the behaviour of the CEMS on A42 and the implementation of a compatible buffer stop design, once implemented, should address the safety issue.

RO-2018-004-SI-02: When A42 collided with buffer stop at Richmond Station No. 2 platform, the reinforced concrete end stop of the buffer stop withstood the impact of the collision and prevented the train from crossing into a pedestrian and main road precinct. The two hydro-pneumatic rams on the front of the buffer stop did not perform their intended function. They were not aligned with the front of the Waratah train and instead of absorbing energy from the collision, they penetrated the cavity either side of the front-of-train coupler.

Closed-Adequately addressed

The ATSB notes that the action to replace the buffer stops at Richmond, once implemented, should address the safety issue.

RO-2018-004-SI-03: Sydney Trains' risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when there were deficiencies in the buffer stop design at Richmond and at other locations.

Closed-Adequately addressed

The ATSB notes that the action initiated by Sydney Trains, once implemented, should address the safety issue.

RO-2018-004-SI-04: Sydney Trains' risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances where the presence of an intermediate train stop at Richmond may have reduced the risk of trains approaching the station at excessive speed.

Open - Safety action still pending

The ATSB notes that the action taken at Richmond has addressed the safety issue. The implementation of ATP, when complete, should address the issue network-wide.

RO-2018-004-SI-05: The rostering of the driver in the days leading up to the incident was inconsistent with Sydney Trains' rostering procedures.

Open - Safety action still pending

Safety issue

Status

Status justification

RO-2018-007: Collision with floodwater involving freight train 6792, Little Banyan Creek, Queensland, on 7 March 2018

RO-2018-007-SI-01: Queensland Rail did not have an effective means of ensuring that, during situations such as a condition affecting the network (CAN), network control personnel were aware of the relevant weather monitoring systems that were unserviceable.

Closed-Adequately addressed

The ATSB is satisfied that the safety actions taken by Queensland Rail will reduce the risk of this safety issue.

RO-2018-007-SI-02: Queensland Rail did not have procedures that required network control personnel to actively search for information about track conditions ahead of a train during situations such as a condition affecting the network (CAN), when conditions had the realistic potential to have deteriorated since the last patrol or train had run over the relevant sections.

Closed-Adequately addressed

The ATSB is satisfied that the safety actions taken by Queensland Rail will reduce the risk of this safety issue.

RO-2018-007-SI-03: Queensland Rail did not have any restrictions on the distance or time that controlled speed could be used as a risk control for safe train operation in situations such as a condition affecting the network (CAN). The effectiveness of controlled speed has the significant potential to deteriorate over extended time periods due to its effect on driver workload, vigilance, fatigue and risk perception.

Safety action still pending

RO-2018-007-SI-04: Aurizon’s procedures and guidance for two-driver operation during situations such as a condition affecting the network (CAN) did not facilitate the effective sharing of duties and teamwork to minimise the potential effects of degraded conditions on driver workload and fatigue.

Safety action still pending

Safety issue

Status

Status justification

RO-2018-010: Track obstruction due to loss of freight from train 7WB3 and subsequent impact of passenger train NT32 with track obstruction near Telegraph Point, New South Wales, on 17 June 2018

RO-2018-010-SI-01: While the Freight Loading Manual was available to customers, Pacific National did not actively advise them when they had a responsibility identified by the manual. Further, they did not have a process for ensuring that customers complied with the manual’s requirements.

Closed-Adequately addressed

The ATSB is satisfied that Pacific National has developed and implemented processes which increase customer awareness of, and compliance with their Freight Loading Manual requirements.

RO-2018-010-SI-02: Pacific National's training course for the loading and securing of freight, and their verification of competency checks for inspection staff, did not include the Freight Loading Manual requirements for non-standard and modified containers.

Closed-Adequately addressed

The ATSB is satisfied that Pacific National has developed and implemented processes to ensure that terminal operators are trained in, and practice their Freight Loading Manual requirements.

Safety issue

Status

Status justification

RO-2018-015: Non-Operation of level crossing protection at Colac, Victoria on 22 September 2018

RO-2018-015-SI-01: V/Line did not have a documented detailed process for inhibiting and reinstating level crossing protection equipment.

Closed-Adequately addressed

The ATSB is satisfied that the safety action taken by V/Line addresses the safety issue.

Safety issue

Status

Status justification

RO-2018-019: Parting of Metro Trains Melbourne passenger train TD 3817 at Croydon, Victoria on 9 November 2018

RO-2018-019-SI-01: The wiring error was not detected by Metro Train Melbourne’s verification program.

Closed-Adequately addressed

Safety action taken by Metro Trains Melbourne will mitigate the risk of future wiring errors with respect to this modification.

Safety issue

Status

Status justification

RO-2018-020: Signalling irregularity involving train DP41, Eagle Junction, Queensland, on 23 September 2018

RO-2018-020-SI-01: Queensland Rail did not have a procedure in place to cross-check a master circuit diagram with the existing configuration of the in-field equipment before using the diagram for safety critical work. This removed an opportunity to detect any error in master circuit diagrams.

Closed-Adequately addressed

The ATSB is satisfied that the action taken by Queensland Rail will ensure that any errors with a master circuit diagram will be identified prior to the installation of new equipment.

Safety issue

Status

Status justification

RO-2018-021: Near miss with rail safety worker by trains 89-K and 88-C, near Redfern, New South Wales, on 8 September 2018

RO-2018-021-SI-01: Sydney Trains' control of the access and egress to the project worksite did not ensure that all workers entering the worksite were identified and received an induction.

Safety action still pending

Safety issue

Status

Status justification

RO-2019-010: Derailment of freight train 7MB9, Goulburn, New South Wales on 31 March 2019

RO-2019-010-SI-02: Post-incident inspection of the derailment site identified a number of factors that increased the risk of a derailment in the refuge and main line. ARTC’s maintenance activities had identified some but not all of these factors prior to the derailment

Safety action still pending

RO-2019-010-SI-03: ARTC's network rules did not provide suitable guidance to assess continued safe operation when responding to track circuit faults. Additionally, the network rules permitting signals to be passed at Stop did not require a reduction in speed when the condition of the track was unknown.

Safety action still pending