Investigation

AO-2013-226: In-flight break-up involving de Havilland DH 82A Tiger Moth, VH-TSG, 300 m east of South Stradbroke Island, Queensland, 16 December 2013

Safety issue

Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life-limits, were appropriately considered.

Number

AO-2013-226-SR-044

Organisation

Civil Aviation Safety Authority

Recommendation

The ATSB recommends that the Civil Aviation Safety Authority takes action to provide assurance that all of the replacement parts that were approved for Australian Parts Manufacturer Approval by the Regulatory Reform Program Implementation team in 2003 have appropriately considered important service factors, such as service history and life limits.

Released

21 January 2016

Final action

18 February 2020

Final action

On 19 April 2016, the ATSB advised that CASA's response did not adequately address the safety issue. CASA has subsequently reviewed its original response to ATSB safety recommendation AO-2013-226-SR-044 and developed an alternative approach to achieving an acceptable level of safety assurance. Consequently, CASA will not be issuing a directive to all CAR 35 design holders to provide CASA with information in relation to APMA approvals as previously advised.
…
CASA undertook the following activities to make a determination if a reasonable level of safety assurance was already apparent:
  An evidence-based review of the CASA Service Difficulty Report (SDR) database was conducted to examine the number of APMA part failures. Systemic issues affecting APMA approvals would be consistent with a disproportionately higher rate of premature failure of APMA parts, whether they comprise critical airworthiness parts or not, in comparison with the Original Equipment Manufacturer (OEM) parts they replaced; and
  An engineering study of the specific manufacturer of the failed tie-rod parts, J&R Aerospace, was conducted. J&R Aerospace manufactured a significant proportion of all APMA parts in Australia. The study [emphasis added]:
a) Reviewed the APMA list of J&R Aerospace parts for any that may be considered critical components likely to be life limited or subject to airworthiness limitations.
b) Performed an analysis of a selected sample of those parts to identify the presence of any design or service life deficiencies. That included determining if the OEM part, upon which the APMA part was designed to replace, also suffered any similar design or service life deficiencies.
c) Sought to establish if there was any evidence of unsafe conditions present in any of the target group of parts.
The analysis of the available SDR data indicated that the J&R parts failure rate was 0.3%. The combined failure rate for all other APMA manufacturers was 1.07%. J&R accounted for 56% of all APMA part types manufactured. The sixteen other APMA manufacturers comprised 44% of the total APMA part types manufactured.
Further analysis was conducted to determine if the failure rate of all APMA parts was, on average, over represented compared to OEM parts. The analysis determined that the failure rate of APMA parts was not over represented compared to OEM parts. In addition, no individual APMA manufacturer exhibited an unusually high failure rate for any of its manufactured parts compared to the equivalent OEM part.
The data indicated that there were no apparent safety issues with any of the APMA parts reviewed. It is CASA's considered view that this provides a reasonable level of safety assurance that parts manufactured under an APMA have appropriately considered service factors, such as service history, life-limits, and airworthiness directives. CASA proposes that the above alternative approach has addressed the safety concern highlighted by the ATSB.

Investigation

AO-2014-190: Further investigation of AO-2009-072 Ditching - IAI Westwind 1124A, VH-NGA, Norfolk Island, 18 Nov 2009

Safety issue

Although air ambulance flights involved transporting passengers, in Australia they were classified as ‘aerial work’ rather than ‘charter’. Consequently, they were subject to a lower level of regulatory requirements than other passenger-transport operations (including in terms of requirements for fuel planning of flights to remote islands).

Number

AO-2014-190-SR-044

Organisation

Civil Aviation Safety Authority

Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority continue reviewing the requirements for air ambulance / medical transport operations and address the limitations associated with the current classification of these flights as aerial work rather than air transport.

Released

23 November 2017

Final action

03 February 2020

Final action

In December 2018, Civil Aviation Safety Regulation (CASR) Parts 121, 135 and 133 were introduced. CASR Part 121 outlined requirements for Australian air transport operations for large aeroplanes (that is, aeroplanes with a maximum operational passenger seat configuration of more than 9 or a maximum take-off weight of more than 8,618 kg). Part 135 outlined requirements for Australian air transport operations for smaller aeroplanes, and Part 133 outlined requirements for Australian air transport operations for rotorcraft. These regulations come into force in March 2021.

In April 2019, relevant definitions associated with these Parts were amended or introduced. These definitions included the following:

An air transport operation is a passenger transport operation, a cargo transport operation, or a medical transport operation, that:

(a) is conducted for hire or reward; or

(b) is prescribed by an instrument issued under regulation 201.025.

A medical transport operation is an operation:

(a) the primary purpose of which is to transport one or more of the following:

(i) medical patients;

(ii) medical personnel;

(iii) blood, tissue or organs for transfusion, grafting or transplantation; or

(b) of a kind prescribed by the Part 119 Manual of Standards for the purposes of this paragraph.

passenger transport operation:

(a) means an operation of an aircraft that involves the carriage of passengers,

whether or not cargo is also carried on the aircraft; but

(b) does not include the following:

(i) an operation of an aircraft with a special certificate of airworthiness;

(ii) a cost-sharing flight;

(iii) a medical transport operation.

Investigation

AO-2014-190: Further investigation of AO-2009-072 Ditching - IAI Westwind 1124A, VH-NGA, Norfolk Island, 18 Nov 2009

Safety issue

The available regulatory guidance on in-flight fuel management and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert.

Number

AO-2014-190-SR-043

Organisation

Civil Aviation Safety Authority

Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority continue its work to address the limitations associated with the requirements and guidance for in-flight fuel management.

Released

23 November 2017

Final action

31 October 2019

Final action

On 31 October 2019, CASA provided the following response to the ATSB question and some additional information.

CASA Instrument 29/18 will be deleted upon the commencement of the future flight operational CASR Parts in March 2021. Its requirements will be appropriately transcribed into relevant Manuals of Standards.

These [in-flight fuel management] requirements are best explained in the context of the existing CASA Instrument 29/18, the contents and requirements of which are being moved to all Manuals of Standards although minor modifications will be made to the content transferred into the Part 121 MOS to accommodate the introduction of an ICAO based isolated aerodromes (and wider alternate aerodromes requirements) policy.

1. In-flight checks of aircraft fuel quantity, at regular intervals, is required by subsection 6(2) of CASA 29/18.

2. For the other 3 matters raised, these requirements are not specifically stated, and do not need to be, as they are inherent in the application of the stated legal requirements of CASA Instrument 29/18. The requirement to conduct regular in-flight fuel checks is phrased to require the PIC to determine whether the usable fuel remaining is sufficient to complete the planned flight. If this flight was planned to involve the use of a decision point, then by necessity the decision point would have to have been calculated and, noting the requirements of section 4 of the instrument in relation to the matters that must be taken into account to calculate usable fuel, meteorological reports and forecasts must be incorporated into any such calculation. Additionally, the requirements of paragraph 7(1)(b) of the instrument for procedures in the event that an in-flight fuel check results in a determination that there is insufficient fuel to complete the flight to the destination aerodrome means that the PIC must calculate a decision point. Additionally, the nature of the legal definition of the term decision point is such that the PIC cannot rely on a pre-flight calculation of where the exact location of the decision point is due to the fact that the definition of the term does not incorporate a time-based component, i.e. the term is not expressed to be a “pre-flight” calculation.

Investigation

AO-2017-005: Collision with terrain following an engine power loss involving Cessna 172M, VH-WTQ

Safety issue

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.

Number

AO-2017-005-SR-026

Organisation

Civil Aviation Safety Authority

Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to improve its procedures and guidance for scoping surveillance activities to address this safety issue.

Released

17 October 2019

Final action

04 March 2020

Final action

CASA provided the ATSB a copy of the new Surveillance planning and scoping development form and an example of the new Operator risk profile.

Investigation

AO-2017-005: Collision with terrain following an engine power loss involving Cessna 172M, VH-WTQ

Safety issue

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.

Number

AO-2017-005-SR-027

Organisation

Civil Aviation Safety Authority

Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority consider mandating the fitment of upper torso restraints (UTRs) for all seats in small aeroplanes and helicopters, particularly for those aircraft (a) being used for air transport operations and/or (b) for those aircraft where the aircraft manufacturer has issued a mandatory service bulletin to fit UTRs for all seats (or such restraints are readily available and relatively easy to install).

Released

17 October 2019

Final action

21 January 2020

Final action

To inform our approach in improving safety particularly in small air transport operations, CASA recently undertook a sector risk profile for the small aeroplane air transport sector. The sector risk profile considered a wide range of information, including the accident and incident data for these types of aircraft, to develop the most critical ‘risks’ or safety issues for this sector. The types of restraints used for rear seat passengers was not identified as a ‘risk’ or safety issue.

As a result of the sector risk profile, and other considerations, CASA is proposing to adopt the following safety enhancements to Part 135 operations (small air transport): new

  training and checking requirements

  safety management systems,

  consideration of human factors in operations and maintenance.

Furthermore, in addressing an outstanding ATSB safety recommendation, AO-2011-115-SR-050, CASA is removing the option of a generic maintenance schedule (CAR ‘Schedule 5’) for aircraft in air transport operations. This is currently the subject of a policy making proposal.

CASA is of the view some of these safety enhancements are a more appropriate focus of mandatory action.

Summary

CASA acknowledges fitting upper torso restraints (UTR) has merit and encourages operators to do so. CASA intends to address this recommendation by issuing an Airworthiness Bulletin for the relevant aircraft that will outline the safety benefits of fitting these types of UTR. It will be the responsibility of owners and operators to decide the merits of fitment.

CASA is of the view it is better to take a systems approach to making safety enhancements when issuing mandatory action, unless clear safety deficiencies exist. CASA is not convinced that these aircraft are unsafe without UTR restraints. CASA intends to mandate a number of other safety enhancements to small air transport operations.

Investigation

AO-2017-098: Pressurisation event involving AirAsia Indonesia Airbus A320, PK-AXD, 160 NM north of Perth, Western Australia, 15 October 2017

Safety issue

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.

Number

AO-2017-098-SR-021

Organisation

AirAsia Indonesia

Recommendation

The ATSB recommends that AirAsia Indonesia take further action to review their current passenger pre-flight safety briefing and safety information card to ensure passengers are provided with additional information in order to better understand how to use their oxygen masks in an emergency.

Released

27 November 2019

Final action

23 June 2020

Final action

The said Safety Information Cards (SIC) have been implemented and distributed on the aircraft. Distribution was conducted on April 27 as stated in the email attached. Please find attached email as the sample for further information regarding SIC distribution to aircraft.

Investigation

AR-2013-107: Engine failures and malfunctions in light aeroplanes: 2009 to 2014

Safety issue

Thicker 7/16 inch diameter through-bolts, fitted to newer Jabiru engines and some retro-fitted engines, have had limited service to date to confirm early indications that they reduce this risk. Retro-fitting engines with thicker through-bolts has only been recommended for aircraft involved in flight training by JSB031 issue 3. Most light aircraft in service with Jabiru engines continue to use 3/8 inch diameter engine through-bolts which, even after upgrades in accordance with Jabiru service bulletins JSB031 issues 1 and 2, remain at an elevated risk of fracturing within the service life of the bolt, leading to an engine failure or malfunction in flight.

Number

AR-2013-107-SR-056

Organisation

Civil Aviation Safety Authority

Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority continue to monitor the through-bolt failure rate of Jabiru engines to satisfy themselves of the reliability of the:  7/16 inch diameter bolts, and   any other alternative produced to replace the existing 3/8 inch diameter through-bolt configuration (including newly developed through-bolts incorporating aspects to alleviate the effects of thermal expansion and damp resonant vibrations)to determine if these modifications have sufficiently reduced the risk of an engine failure or malfunction in Jabiru-powered aircraft.

Released

9 March 2016

Final action

22 November 2019

Final action

CASA accepted this recommendation and provided a response indicating that CASA will take appropriate action to monitor the through-bolt failure rate of Jabiru engines through Airworthiness Direction processes and Service Difficulty Reporting.

CASA has now determined (June 2019) that the continuation of the safety measures in instrument CASA 39/19 (and its predecessors) is warranted for a further period of 3 years. During this period, CASA will continue to monitor the instances of loss-of-engine-power events in relation to the aircraft, to ensure the safety measures in the instrument remain effective. CASA believes that this instrument sufficiently reduced the risk of an engine failure or malfunction in Jabiru-powered aircraft and will continue to monitor for another 3-year period to determine reliability of the 7/16-inch diameter bolts.

Investigation

RO-2017-013: Derailment of acid train 9T90 near Kimburra, Queensland, on 28 September 2017

Safety issue

Anomalies in the magnetic particle inspection procedures likely led to the crack not being detected.

Number

RO-2017-013-SR-007

Organisation

Aurizon

Recommendation

The Australian Transport Safety Bureau recommends that Aurizon addresses the non-use of standard test pieces during magnetic particle inspection.

Released

13 June 2019

Final action

03 December 2019

Final action

Aurizon have published a revised Work Instruction “Inspection and Reconditioning of Wheelsets V2.0”, and “MPI Record Sheet for Wheelsets V1.0”, both dated 25 November 2019.