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Safety Action

Summary

Local Safety Action

As a result of aspects of this occurrence, and an audit carried out by a cabin safety specialist, the operator has instigated several changes to their standard operating procedures, pre-flight crew briefings and aircrew training. The emergency briefing cards situated in the aircraft have also been updated.

In an effort to address the difficulty some of the passengers had in hearing the in-flight emergency briefing, the volume of the aircraft's public address system has been adjusted. The flight attendant's reversion to an oral emergency brief following a public address system failure, has also been formalised.

As a result of the ATSB investigation into this occurrence the following recommendations are simultaneously issued:

R20000109

The Australian Transport Safety Bureau recommends that Pratt and Whitney Canada investigate the re-instigation of regular borescope inspections of PW118A reduction gear-box input shafts with below recommended thickness carburised case depth (pre SB 21323), regardless of the Service Bulletin state of the engine.

R20000110

The Australian Transport Safety Bureau recommends that Transport Canada investigate the need for regular borescope inspections of PW118A reduction gear-box with below recommended thickness carburised case depth (pre SB 21323), regardless of the Service Bulletin state of the engine.

R20000111

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority investigate the need for regular borescope inspections of PW118A reduction gear-box input shafts with below recommended thickness carburised case depth (pre SB 21323), regardless of the Service Bulletin state of the engine.

R20000112

The Australian Transport Safety Bureau recommends that Pratt and Whitney Canada develop a more appropriate non-destructive method of assessing the serviceability of the PW118A reduction gearbox input shafts at overhaul.

Annexes

  1. Pratt and Whitney Canada, Engine/Component Investigation Report.
  2. Pratt and Whitney Canada, Materials Investigation, Laboratory Report.


 
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