The engineering justification supporting Australian supplemental type certificate SVA521 did not contain consideration of the effect an increase in the average operating speed could have on the rate of fatigue damage accumulation.
Important information relating to Civil Aviation Safety Authority (CASA) airworthiness directive AD/PZL/5 was not contained in CASA’s airworthiness directive file, but on other CASA files with no cross-referencing between those files. This impacted CASA’s future ability to reliably discover that information and make appropriately‑informed decisions regarding the airworthiness directive.
The eddy current inspection used on VH-TZJ, and other M18 aircraft, had not been approved by the Civil Aviation Safety Authority as an alternate means of compliance to airworthiness directive AD/PZL/5. This exposed those aircraft to an inspection method that was potentially ineffective at detecting cracks in the wing attachment fittings.
The spin recovery methods taught by the flying school were inconsistent across instructors and training material, and were not always appropriate for the Chipmunk aircraft type used by the school.
The manufacturer’s quality system did not prevent non-conforming tie rods from being released for use on aircraft.
When approving the change in material for the manufacture of the replacement tie rods, the design engineer did not identify that the original parts had a life limitation, or that they had shown susceptibility to fatigue cracking. As a result, the engineer did not compare the fatigue performance of the alternative design to the original, and the replacement tie rods were manufactured to that design and released into service with an unknown fatigue life.
It was likely that, because of the Civil Aviation Safety Authority’s policy at the time, their engineering assessment of the tie rod design for inclusion in the manufacturer’s Australian Parts Manufacturer Approval did not consider the service history of the original tie rods or identify that they were subject to airworthiness directive AD/DH 82/10. Consequently, the assessment team was likely unaware that the original tie rods were subject to a life limitation, and did not require the life limits for the replacement tie rods to be established.
Although a number of aerobatic manoeuvres were permitted in Tiger Moth aircraft, there was no limitation on the amount of aerobatic operations that was considered to be safe. As a result, operators may be unaware that a high aerobatic usage may exceed the original design assumptions for the aircraft.
Together with a number of other Australian Tiger Moths, VH-TSG was fitted with non‑standard Joint H attachment bolts that did not conform to the original design with the result that the integrity of the Joint H could not be assured.
The JRA-776-1 fuselage lateral tie rods that were inspected by the ATSB were not appropriately marked with part and serial numbers, affecting the traceability and service history of the parts in a number of aircraft.
Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life‑limits, were appropriately considered.
Debris originating from the starter failure was not contained by the starter casing and severed the number one engine B-sump oil scavenge pipe.
The Flight Crew Operating Manual procedure for crew comparison of the calculated Vref40 speed, while designed to assist in identifying a data entry error, could be misinterpreted, thereby negating the effectiveness of the check.
The applicability of a general requirement to conduct aviation risk assessments for complex, new, unusual or irregular activities was open to interpretation.
Unlike other Australian standard arrival routes that included a visual segment, the visual approach to runway 34 at Melbourne via the SHEED waypoint could be issued to super or heavy jet aircraft operated by foreign operators, despite there being more occurrences involving the SHEED waypoint than other comparable approaches.
The LIZZI FIVE RWY 34 VICTOR ARRIVAL required a 3.5° descent profile after passing the SHEED waypoint for visual approach to runway 34 at Melbourne, increasing the risk of an unstable approach.
Air traffic control did not, and was not required to provide traffic information to aircraft using adjacent runways and abeam each other during independent visual approach procedures at Sydney.
The Virgin Australia procedures did not require its flight crews to, whenever practicable, announce flight mode changes.
The presentation of the runway 34 visual approach in the operator's Route and Airport Information Manual increased the risk of the runway threshold crossing altitude being entered into the runway extension waypoint.
Qantas provided limited guidance on the conduct of a visual approach and the associated briefing required to enable the flight crew to have a shared understanding of the intended approach.
