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

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

Investigation

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

Safety issue

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 key safety risks associated with the conduct of the air display were not adequately managed.

Number

AO-2017-013-SR-029

Organisation

Civil Aviation Safety Authority

Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to enhance their tools and guidance for air display approval and oversight, and procedures to ensure the suitability of those responsible for organising, coordinating and participating in air displays.

Released

19 November 2019

Investigation

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

Safety issue

Angel Flight did not consider the safety benefits of commercial passenger flights when suitable flights were available.

Number

AO-2017-069-SR-015

Organisation

Angel Flight Australia

Recommendation

The Australian Transport Safety Bureau recommends that Angel Flight Australia takes action to enable it to consider the safety benefits of using commercial flights where they are available to transport its passengers.

Released

13 August 2019

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

Investigation

AO-2018-007: Engine failure or malfunction involving an Airbus A330, registered 9M-MTM, near Curtin, WA, 18 January 2018

Safety issue

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.

Number

AO-2018-007-SR-021

Organisation

Pratt and Whitney (P & W)

Recommendation

The ATSB recommends that Pratt & Whitney, together with the United States Federal Aviation Administration, take action to maximise incorporation of the redesigned outer transition duct as detailed in Service Bulletin PW4G-100-A72-261.

Released

07 November 2019

Investigation

AO-2018-007: Engine failure or malfunction involving an Airbus A330, registered 9M-MTM, near Curtin, WA, 18 January 2018

Safety issue

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.

Number

AO-2018-007-SR-021

Organisation

Pratt and Whitney (P & W)

Recommendation

The ATSB recommends that Pratt & Whitney, together with the United States Federal Aviation Administration, take action to maximise incorporation of the redesigned outer transition duct as detailed in Service Bulletin PW4G-100-A72-261.

Released

07 November 2019

Investigation

AO-2018-007: Engine failure or malfunction involving an Airbus A330, registered 9M-MTM, near Curtin, WA, 18 January 2018

Safety issue

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.

Number

AO-2018-007-SR-022

Organisation

US Federal Aviation Administration

Recommendation

The ATSB recommends that the United States Federal Aviation Administration, together with Pratt & Whitney, take action to maximise incorporation of the redesigned outer transition duct as detailed in Service Bulletin PW4G-100-A72-261.

Released

07 November 2019

Investigation

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

Safety issue

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.

Number

AO-2018-025-SR-012

Organisation

Civil Aviation Safety Authority

Recommendation

The ATSB recommends the Australian Civil Aviation Safety Authority include guidance for the inclusion of a safe runway overrun area in the Civil Aviation Advisory Publication for Aeroplane Landing Areas (92-1(1))

Released

22 October 2019

Investigation

RO-2018-004: Collision of passenger train 150E with bufferstop at Richmond NSW on 22 January 2018

Safety issue

The rostering of the driver in the days leading up to the incident was inconsistent with Sydney Trains' rostering procedures.

Number

RO-2018-004-SR-020

Organisation

Sydney Trains

Recommendation

The Australian Transport Safety Bureau recommends that Sydney Trains take safety action to ensure that existing procedures regarding adequate rest breaks between shift cycles and start time rotations are reinforced to safeguard against fatigue impairment of train crew.

Released

20 December 2019