The priority level of the battery discharge messages that were provided by the engine indicating and crew alerting system did not accurately reflect the risk presented by the battery discharge status.
Maintenance processes did not identify or correct the inoperability of the forward drain line heater.
Maintenance processes did not identify or correct the deterioration of the galley floor sealing
Maintenance processes did not identify or correct the corrosion in the generator control units.
Maintenance processes did not identify or correct the deterioration of the drip shield.
The aircraft operator’s documented design objectives did not explicitly require the protection of non-structural systems from liquid contact or ingress.
The operator’s flight crew quick reference handbook did not include sufficient information for flight crew to manage the emergency.
The galley drain operation and maintenance processes did not adequately prevent blockage and overflow of the aircraft’s drain lines.
The Aerial Agricultural Association of Australia suggestion that an additional hazard identification check be carried out prior to a cleanup run was not routinely practiced by the pilots, or monitored by the operator.
The removal of fluid quantity markings from, and unapproved modifications to the helicopter’s spray tank by the operator increased the risk of overweight operations
Neither the maintenance provider, nor the helicopter operator appreciated the potential significance of mid-span transposition information to the joint testing task.
The operator's joint testing procedures were not comprehensive with respect to hazard identification and the use of standard phraseology.
There was no direct supervision of the joint testing operations.
The recording lineworker’s shoulder restraint had been repaired using an unapproved stitch pattern and density.
On 30 November 2010 the ATSB had, in close consultation with Rolls-Royce and the UK Air Accidents Investigation Branch, established that the occurrence was directly related to the fatigue cracking of an oil feed stub pipe within the No.2 engine’s HP/IP bearing support structure. The ATSB identified the following safety issue:
Practices used within the ATS Group did not ensure that NOTAMs were effectively reviewed and communicated.
The Out of Hours telephone numbers for Proserpine Airport, listed in the Jeppesen Airways Manual, were incorrect.
There were no published communications procedures or phraseology that should before used by pilots during firebombing operations to provide separation assurance at fire locations when there was no air attack supervisor present.
The lack of guidance material for the supervision of a pilot with an Agriculture Pilot (Aeroplane) Rating Grade 2 increases the risk of inadequate supervision of such a pilot
Confusion within the aerial application industry concerning the correct authorisation for a supervisor of a pilot with an Agriculture Pilot (Aeroplane) Rating Grade 2 (Ag 2) increases the risk of an inappropriately qualified person supervising such a pilot.
