The Job Hazard Analysis (JHA) for disconnecting from the CALM buoy did not provide an accurate assessment of the all of the hazards and associated risks in performing the task. In addition, the crew did not use it to assess the risks associated with undertaking an unfamiliar operation and it was reviewed without any involvement from the crew. Consequently, the JHA was not an effective means for assessing and controlling the risks associated with the operation of disconnecting from the CALM buoy.
The servo valve within the left green aileron servo was incorrectly adjusted during manufacture.
The aircraft operator did not comply with the reporting requirements of the Transport Safety Investigation Act 2003.
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.
There were no specific training requirements for Robinson helicopters in Australia, such as those in Federal Aviation Administration Special Federal Aviation Regulation 73-2.
The CFM56-7B engine had sustained bushing and shroud wear sufficient to cause rotor-to-stator contact, after a time in service that was less than the minimum threshold period specified by the manufacturer, for an initial inspection targeted at identifying this problem
The CFM56-7B engine design was susceptible to VSV bushing and shroud wear that can lead to internal mechanical damage and potential in-flight performance difficulties.
The flight planning requirements at page 88 of the Visual Flight Guide included a transcription error that inadvertently limited the application of the requirements of Civil Aviation Regulation 239.
The current advice in Civil Aviation Advisory Publication 5.81-1(0) Flight Crew Licensing Flight Reviews in relation to the assessment of navigation skills, represents a missed opportunity to identify a pilot's capacity to make safe and appropriate decisions during cross country flying.
There was no Australian requirement for endorsement and recurrent training conducted on Robinson Helicopter Company R22/R44 helicopters to specifically address the preconditions for, recognition of, or recovery from, low main rotor RPM.
There was a lack of assurance that informal operator supervisory and experience-based policy, procedures and practices minimised the risk of pilots operating outside the individual pilot’s level of competence.
