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Safety recommendations released in 2020-21

Aviation

Table 11: Aviation – Safety recommendations released in 2020–21

Investigation

AO-2017-118 Collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, NSW on 31 December 2017

Safety issue

Annex 6 to the Convention of International Civil Aviation did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and numerous other accidents, have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in important safety issues not being identified, which may remain a hazard to current and future passenger-carrying operations.

Number

AO-2017-118-SR-048

Organisation

International Civil Aviation Organization

Recommendation

The ATSB recognises that the International Civil Aviation Organization has developed technical standards for lightweight recorders and airborne image recorders. However, despite the known benefits for the identification of safety issues, the fitment of such devices for passenger-carrying aircraft with a maximum take-off weight less than 5,700 kg is not mandated. The ATSB recommends that the International Civil Aviation Organization takes safety action to consider the safety enhancement of these devices to passenger-carrying operations.

Released

29 January 2021

Investigation

AO-2017-118 Collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, NSW on 31 December 2017

Safety issue

Australian civil aviation regulations did not mandate the fitment of flight recorders for passenger-carrying aircraft under 5,700 kg. Consequently, the determination of factors that influenced this accident, and other accidents, have been hampered by a lack of recorded data pertaining to the flight. This has likely resulted in the non‑identification of safety issues, which continue to present a hazard to current and future passenger-carrying operations.

Number

AO-2017-118-SR-049

Organisation

Civil Aviation Safety Authority

Recommendation

The ATSB recommends that CASA consider mandating the fitment of onboard recording devices for passenger-carrying aircraft with a maximum take-off weight less than 5,700 kg.

Released

29 January 2021

Investigation

AO-2017-118 Collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, NSW on 31 December 2017

Safety issue

There was no regulatory requirement from CASA for piston‑engine aircraft to carry a carbon monoxide detector with an active warning to alert pilots to the presence of elevated levels of carbon monoxide in the cabin.

Number

AO-2017-118-SR-050

Organisation

Civil Aviation Safety Authority

Recommendation

The ATSB recommends that CASA takes further safety action to enable it to consider mandating the carriage of carbon monoxide detectors in piston-engine aircraft, particularly passenger-carrying operations.

Released

29 January 2021

Investigation

AO-2018-006 Rotor RPM decay and hard landing involving Robinson R44, VH-HGX, 5 km south of Ayers Rock Airport, NT, on 17 January 2018

Safety issue

The Robinson R44 pilot’s operating handbook low rotor RPM recovery procedure did not include reference to the minimum power airspeed for the helicopter as a consideration, which may assist a pilot to recover from a low rotor RPM condition.

Number

AO-2018-006-SR-053

Organisation

Robinson Helicopter Company

Recommendation

The ATSB recommends that the Robinson Helicopter Company reviews the R44 pilot's operating handbook low rotor RPM recovery procedure for consideration to include a reference to the minimum power airspeed (Vy) for pilot awareness.

Released

7 October 2020

Investigation

AO-2018-026 Loss of control and collision with water involving Eurocopter EC120B, VH-WII, Hardy Reef, Whitsundays, Qld, on 21 March 2018

Safety issue

Due to multiple factors, the design of the rear left sliding door (emergency exit) on the EC120B helicopter was not simple and obvious to use unless the occupant was provided with specific instructions about how to operate the exit. In particular:

  • the door required three actions to open (pull handle up, push door out, slide door back), and the second action was not indicated in either the design of the handle or the placard next to the handle
  • the design of the inside handle was such that its purpose may not have been readily apparent to many users.

Number

AO-2018-026-SR-073

Organisation

Airbus Helicopters

Recommendation

The ATSB recommends that Airbus Helicopters takes safety action to address the safety issue associated with the design of the rear left sliding door on the EC120B helicopter to ensure that, as best as possible, the door is simple and obvious to use and/or passengers are provided with sufficient instructions so that it is simple and obvious to use.

Released

16 June 2021

Investigation

AO-2018-027 Controlled flight into terrain involving Kavanagh Balloons G-525, VH-HVW, Pokolbin, NSW, on 30 March 2018

Safety issue

The visual flight rules permitted balloons to arrive and depart in foggy conditions without assurance that sufficient visibility existed to see and avoid obstacles.

Number

AO-2018-027-SR-044

Organisation

Civil Aviation Safety Authority

Recommendation

The ATSB recommends that CASA undertake a risk assessment of the reduced visibility exemption to the visual flight rules for balloons, to determine whether it assures an adequate level of safety. Furthermore, that CASA publishes any required mitigating factors identified from the risk assessment that are necessary to operate safely in the reduced visibility conditions.

Released

11 August 2020

Investigation

AO-2018-049 Uncommanded engine shutdown involving De Havilland Aircraft of Canada DHC-8, VH-LQD, 77 km north-north-west of Brisbane Airport, Qld, on 26 June 2018

Safety issue

The procedures in the aircraft maintenance manual relating to chip detector debris analysis were written in a way that could cause confusion and error. This probably influenced the actions of the maintenance personnel to release the aircraft to service with a deteriorating bearing.

Number

AO-2018-049-SR-050

Organisation

Pratt & Whitney Canada

Recommendation

The ATSB recommends that Pratt & Whitney Canada takes safety action to improve the clarity of procedures within the chip detector debris analysis section of the aircraft maintenance manual.

Released

16 September 2020

Investigation

AO-2019-060 Engine failure during take-off involving Bombardier Dash 8, VH-ZZE, at Darwin Airport, NT, on 11 November 2019

Safety issue

The power turbine shaft in Pratt & Whitney Canada PW100 series engines operating in certain marine environments is susceptible to corrosion pitting, which can grow undetected between scheduled inspections. This increases the risk of shaft fracture resulting in engine failure.

Number

AO-2019-060-SR-043

Organisation

Pratt & Whitney Canada

Recommendation

The ATSB recommends that Pratt & Whitney Canada takes safety action to address the risk of corrosion-related fracture of the power turbine shaft in its PW100 series engines.

Released

10 March 2021

Marine

Table 12: Marine – Safety recommendations released in 2020–21

Investigation

MO-2018-011 Fire on board Iron Chieftain, Port Kembla, NSW, on 18 June 2018

Safety issue

The capability of Fire and Rescue NSW to effectively respond to a shipboard fire in Port Kembla, was limited by:

  • a lack of specialised marine firefighting expertise
  • outdated marine training for firefighters
  • relative inexperience in shipboard firefighting associated with the rarity of major shipboard fires
  • an absence of marine-specific firefighting resources and aids for use by first responders.

Number

MO-2018-011-SR-014

Organisation

Fire and Rescue NSW

Recommendation

The ATSB recommends that Fire and Rescue NSW takes further action to address the limited marine firefighting capability in Port Kembla due to the lack of specialised marine firefighting expertise, experience, updated training and resources.

Released

11 May 2021

Investigation

MO-2018-011 Fire on board Iron Chieftain, Port Kembla, NSW, on 18 June 2018

Safety issue

The cargo handling spaces of specialised self-unloading bulk carriers continue to present a very high fire risk due to the inadequacy of standards or regulations for self-unloading systems, including for conveyor belts, and dedicated fire detection/fixed fire-extinguishing systems. This has been a factor in at least three major fires over a 25-year period, including Iron Chieftain’s constructive total loss.

Number

MO-2018-011-SR-015

Organisation

Australian Maritime Safety Authority

Recommendation

The ATSB recommends that AMSA takes steps to formally raise this safety issue with the International Maritime Organization to seek safety action aimed at addressing the risk of fire in the cargo handling spaces of self-unloading bulk carriers due to the inadequacy of the current associated standards/regulations.

Released

11 May 2021

Rail

Table 13: Rail – Safety recommendations released in 2020–21

Investigation

RO-2018-008 Track obstruction due to loss of freight involving train 6WM2 and subsequent impact of passenger train 8615 with track obstruction, near Winton, Vic, on 30 March 2018

Safety issue

Pacific National’s Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of strap breakage due to contact with the cradle.

Number

RO-2018-008-SR-040

Organisation

Pacific National Pty Ltd

Recommendation

The ATSB recommends that Pacific National address the risk presented by continuing to allow jumbo coils to be loaded in an orientation where all the radial straps are positioned within the contact zone between the coil and cradle.

Released

10 December 2020

Investigation

RO-2018-008 Track obstruction due to loss of freight involving train 6WM2 and subsequent impact of passenger train 8615 with track obstruction, near Winton, Vic, on 30 March 2018

Safety issue

Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose.

Number

RO-2018-008-SR-042

Organisation

Pacific National Pty Ltd

Recommendation

The ATSB recommends that Pacific National review the load restraint system provided by the demountable cradle design to demonstrate that they sufficiently restrain jumbo coils against lateral accelerations and prevent coils from moving and falling during transit.

Released

10 December 2020