Neither the maintenance provider, nor the helicopter operator appreciated the potential significance of mid-span transposition information to the joint testing task.
On 30 November 2010 the ATSB had, in close consultation with Rolls-Royce and the UK Air Accidents Investigation Branch, established that the occurrence was directly related to the fatigue cracking of an oil feed stub pipe within the No.2 engine’s HP/IP bearing support structure. The ATSB identified the following safety issue:
Practices used within the ATS Group did not ensure that NOTAMs were effectively reviewed and communicated.
The Out of Hours telephone numbers for Proserpine Airport, listed in the Jeppesen Airways Manual, were incorrect.
There were no published communications procedures or phraseology that should before used by pilots during firebombing operations to provide separation assurance at fire locations when there was no air attack supervisor present.
The lack of guidance material for the supervision of a pilot with an Agriculture Pilot (Aeroplane) Rating Grade 2 increases the risk of inadequate supervision of such a pilot
Confusion within the aerial application industry concerning the correct authorisation for a supervisor of a pilot with an Agriculture Pilot (Aeroplane) Rating Grade 2 (Ag 2) increases the risk of an inappropriately qualified person supervising such a pilot.
The training and assessment system was ineffective, in this case, because it placed an individual with deficiencies in scanning and conflict resolution in a control position.
Cabin crew training facilities did not appropriately replicate the equipment installed within the aircraft, including the drop-down oxygen mask assemblies.
The safety information provided to passengers did not adequately explain that oxygen will flow to the masks without the reservoir bag inflating.
While maintaining the appropriate general quality accreditation (ISO 9001) of its engineering facilities, the operator did not maintain independent accreditation of the specific procedures and facilities used for the inspection, maintenance and re-certification of oxygen cylinders.
Some cabin crew-members did not have an appropriate understanding of the aircraft's emergency descent profile, leading to misapprehensions regarding the significance of the situation.
Some cabin crew-members did not have an appropriate understanding of the oxygen mask flow indication system.
The operator's cabin emergency procedures did not include specific crew actions to be carried out in the event of a PATR failure.
United Treasure’s permit to work aloft system had not been effectively implemented on board the ship. In addition, the standard form for the permit did not ensure that the officer in charge of the work and its authoriser were not the same person and that a risk assessment was formally undertaken by at least two responsible officers.
The tower was not assembled as designed. The outriggers and intermediate planks, both key components, were missing and the work platform guard rails were not used. The manufacturer’s instructions were also missing but no attempt was made to obtain them, a parts list or the missing parts.
While enclosed space entry checklists were being filled out by the crew members on board Bow De Jin, the checklist system was not being used as a proactive means to ensure that the necessary safety requirements were being met prior to tank entries.
