The absence of an altitude deviation alert within the Australian Defence Air Traffic System increases the risk of undetected altitude variation and contributed to the significant loss of altitude.
Interruption of electrical power to the multi purpose flight recorder due to water ingress removed of an important source of information used to identify safety issues.
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.
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 helicopter operator's induction checklist did not include the notation of instructors’ ratings and validity periods.
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 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.
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.
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.
Regulatory guidance regarding the measurement of fuel quantity before flight lacked clarity and appropriate emphasis and did not ensure that the fuel quantity measurement procedures used by operators included two totally independent methods.
There was no regulatory requirement for simulator training in Australia.
Response from CASA: 31/08/2009
CASA will address this issue and will commence a review of the legislation. In the course of that review, CASA will consider whether there is a need to mandate the use of simulators in connection with certain flight crew training requirements in the air transport sector, and other sectors where this may be appropriate.
The absence of simulator training meant that the endorsement and other training the flight crew had undergone did not adequately prepare them for the event.
The practices used by the operator’s pilots for measuring and logging of fuel quantity were inconsistent.
