Atsb transport safety report
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- Proactive industry safety action in aviation
- ATSB Safety Recommendation in aviation
- Summary (Aviation)
- Aviation Safety Recommendations and Safety Advisory Notices (SANs)
Safety actionsAs was shown earlier in Figure 3, the majority of safety actions in all transport modes were proactive actions undertaken by the industry prior to the publication of a formal investigation report. In aviation, 91 per cent of safety actions were carried out proactively by the industry (Figure 12). Figure 12: Safety actions in response to aviation investigations 
Proactive industry safety action in aviationThe vast majority of the proactive industry safety actions were related to procedures and creating or changing documentation (Figure 13). A large number of the proactive industry safety actions associated with safety issues of significant risk involved changing or creating procedures, changing or developing documentation, education and regulatory surveillance. In the 2009-2010 financial year, there were six proactive changes or additions to procedures in response to the significant risks found. One such change followed a consultation between the aircraft manufacturer and the high capacity operator in which the go-around procedure was revised within the manufacturer’s Flight Crew Operating Manual. The aim of that revision was to emphasise the critical nature of the actions by flight crew during a go-around. This revision followed an occurrence where the operator had changed the standard operating procedure for the go-around, resulting in the flight crew being unaware of the flight mode status of the aircraft during the first part of the first missed approach.Error: Reference source not found Figure 13: Proactive industry safety actions in aviation
The Civil Aviation Safety Authority (CASA) also proactively responded to the significant risks identified by conducting regulatory surveillance as a proactive industry safety action. In two cases, CASA actioned follow-ups with the operator regarding their checklist procedures. CASA also issued a series of directions to the operator which addressed fuel quantity measurement procedures and flight crew training, as well as reviewing its guidance material relating to separate processes for fuel quantity measurement checks. In terms of documentation and education, CASA proactively changed its guidance material relating to separate processes for quantity measurement checks and communicated that in the form of a Civil Aviation Advisory Publication (CAAP) also in response to the significant risks found.
The recommendation related to the lack of regulatory requirement for simulator training in Australia, and this safety issue was considered to carry significant risk. On 26 October 2010, CASA issued Notice of Proposed Rule Making - NPRM 1007OS 'Mandatory Flight Simulator Training - Proposed amendments to Civil Aviation Orders (CAOs) 40.0 and 82.0' for industry comment by 21 January 2011. The ATSB is monitoring the progress of this safety action. 
Hard landing - Darwin Airport, Northern Territory (AO- 2008-007) Summary (Aviation)Individual actions and risk controls were commonly identified as safety factors in aviation investigations. The majority of contributing safety factors were also linked with individual actions and risk controls. Issues with procedures were the most common safety issue. These were usually related to the lack of or poor documentation, procedures, or guidance. Of the safety issues assessed as posing a significant risk to aviation safety, over a third were related to procedures, and about 20 per cent were related to regulatory influences. The vast majority of safety issues, including safety issues of significant risk, were associated with flight operations. Most of the safety actions taken by organisations and agencies in responses to safety issues were proactive in nature. Many of the proactive industry safety actions involved changing or creating procedures, and many of these were in response to safety issues of significant risk. Also in response to safety issues of significant risk were the development of or changes to documentation, education, and regulatory surveillance. Aviation Safety Recommendations and Safety Advisory Notices (SANs)Table 7 and Table 8 below provides a short description of all aviation safety recommendations and SANs in the 2009-2010 financial year. Details of these safety actions are found in Appendices B and C. Table 7: Aviation: Safety Recommendations
Table 8: Aviation: Safety Advisory Notices
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