The Auto Release procedures at Melbourne Airport allowed for aircraft to be departed at or close to the separation minima, with no controls in place to ensure aircraft would maintain a minimum speed and flight crews would advise air traffic control if the speed could not be achieved.
A significant number of R44 helicopters, including VH-HFH, were not fitted with bladder-type fuel tanks and the other modifications detailed in the manufacturer's service bulletin 78 that were designed to provide improved resistance to post-impact fuel leaks.
A number of self-locking nuts from other aircraft, of the same specification as that used to secure safety-critical fasteners in VH-HFH, were identified to have cracked due to hydrogen embrittlement.
High service time stage-2 LP turbine blades were susceptible to a reduction in fatigue endurance as a result of vibratory stresses sustained during operation at speeds close to the maximum.
LP turbine support bearings (part numbers LK30313 and UL29651) showed increased susceptibility to breakdown and collapse under vibratory stress conditions associated with LP turbine blade release.
The Australian Transport Safety Bureau encourages all operators and owners of R44 helicopters that are fitted with all-aluminium fuel tanks to note the circumstances of this accident as detailed in this preliminary report. It is suggested that those operators and owners actively consider replacing these tanks with bladder-type fuel tanks as detailed in the manufacturer's Service Bulletin (SB) 78A as soon as possible.
The Williamtown air traffic control procedures did not clearly define the separation responsibilities and coordination requirements between the Approach sectors for departing aircraft.
An important alerting function within the Australian Defence Air Traffic System had been disabled at Williamtown to prevent nuisance alerts.
The Department of Defence’s air traffic controllers had not received training in compromised separation recovery techniques.
The aircraft operator’s flight crews were probably not adequately equipped to manage the vertical profile of non-precision approaches in other than autopilot managed mode.
The operators procedures did not include a validation check of the landing weight generated by the flight management system which resulted in lack of assurance that the approach and landing speeds were valid.
The operators recurrent simulator training did not address the recovery from a stall or stick shaker activation such that the ongoing competency of their flight crew was not assured.
The presentation on the aircraft load sheet of the zero fuel weight immediately below the operating weight, increased the risk of selecting the inapropriate figure for flight management system data entry.
The operator's procedure for confirming the validity of the flight management system generated take-off weight did not place sufficient emphasis on the check against the load sheet.
The available Cross Crew Qualification and Mixed Fleet Flying guidance did not address how flight crew might form an expectation, or conduct a ‘reasonableness' check, of the speed/weight relationship for their aircraft during takeoff.
Single event effects (SEE) have the potential to adversely affect avionics systems that have not been specifically designed to be resilient to this hazard. There were no specific certification requirements for SEE, and until recently there was no formal guidance material available for addressing SEE during the design process.
For the data-spike failure mode, the built-in test equipment of the LTN 101 air data inertial reference unit was not effective, for air data parameters, in detecting the problem, communicating appropriate fault information, and flagging affected data as invalid.
In recent years there have been developments in guidance materials for system development processes and research into new approaches for system safety assessments. However, there has been limited research that has systematically evaluated how design engineers and safety analysts conduct their evaluations of systems, and how the design of their tasks, tools, training and guidance material can be improved so that the likelihood of design errors is minimised.
When developing the A330/A340 flight control primary computer software in the early 1990s, the aircraft manufacturer’s system safety assessment and other development processes did not fully consider the potential effects of frequent spikes in the data from an air data inertial reference unit.
There has been very little research conducted into the factors influencing passengers’ use of seat belts when the seat-belt sign is not illuminated, and the effectiveness of different techniques to increase the use of seat belts.
