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.
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.
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
The training and assessment system was ineffective, in this case, because it placed an individual with deficiencies in scanning and conflict resolution in a control position.
While maintaining the appropriate general quality accreditation (ISO 9001) of its engineering facilities, the operator did not maintain independent accreditation of the specific procedures and facilities used for the inspection, maintenance and re-certification of oxygen cylinders.
Some cabin crew-members did not have an appropriate understanding of the oxygen mask flow indication system.
The safety information provided to passengers did not adequately explain that oxygen will flow to the masks without the reservoir bag inflating.
Some cabin crew-members did not have an appropriate understanding of the aircraft's emergency descent profile, leading to misapprehensions regarding the significance of the situation.
The operator's cabin emergency procedures did not include specific crew actions to be carried out in the event of a PATR failure.
Cabin crew training facilities did not appropriately replicate the equipment installed within the aircraft, including the drop-down oxygen mask assemblies.
Following the separation of the IP turbine disc from the drive arm, the engine behaved in a manner that differed from the engine manufacturer’s modelling and experience with other engines in the Trent family, with the result that the IP turbine disc accelerated to a rotational speed in excess of its design capacity whereupon it burst in a hazardous manner.
The lack of formalised procedures in place requiring the Air Crew Officer (ACO) to monitor key instrument indications probably contributed to the undetected altitude loss.
The design and relative positioning of the external air vent and avionics modules permitted the ingress of moisture and particulates that led to corrosion and contamination of electronic avionics components and consequently the generation of multiple erroneous crew alerting system (CAS) messages due to electrical shorting.
Interruption of electrical power to the multi purpose flight recorder due to water ingress removed of an important source of information used to identify safety issues.
The absence of an altitude deviation alert within the Australian Defence Air Traffic System increases the risk of undetected altitude variation and contributed to the significant loss of altitude.
The aircraft operator did not comply with the reporting requirements of the Transport Safety Investigation Act 2003.
The servo valve within the left green aileron servo was incorrectly adjusted during manufacture.
Fatigue cracking originated within the aircraft nose landing gear (NLG) right axle as the result of surface damage associated with grinding during manufacture, and was probably assisted in its initiation by hydrogen evolved during plating processes.
The helicopter operator's induction checklist did not include the notation of instructors’ ratings and validity periods.
