The United States Federal Aviation Administration regulations and associated guidance material did not fully address the potential harm to flight safety posed by liquid contamination of electrical system units in transport category aircraft.
The floor sealing around the forward galley was not of sufficient extent to prevent liquids from passing through to the under floor area.
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 deterioration of the drip shield.
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.
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.
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.
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.
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:
The Out of Hours telephone numbers for Proserpine Airport, listed in the Jeppesen Airways Manual, were incorrect.
Practices used within the ATS Group did not ensure that NOTAMs were effectively reviewed and communicated.
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.
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.
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.
