With the conclusion of the investigation into this occurrence,
the following recommendations are made:
R20000025
The Australian Transport Safety Bureau (formerly the Bureau of Air
Safety Investigation) recommends that the engine manufacturer
General Electric identify the source of the casting defect of the
failed HPT blade.
R20000026
The Australian Transport Safety Bureau (formerly the Bureau of Air
Safety Investigation) recommends that the engine manufacturer
General Electric review the adequacy of turbine blade manufacturing
process controls to reduce the likelihood of blades containing
casting defects being released into service.
SAN20000027
The Federal Aviation Administration should note the safety
deficiency identified in this document and take appropriate
action.