Duckett, Alan Bernie-Johnson, Bruce William-Hughes, Allen John-Thompson, Katharine Anne

Contributing factors

• Left engine failure or serious malfunction during takeoff
• Inadequate maintenance system and oversight following resignation of maintenance controller in August 2001
• Failure to properly monitor and transmit Engine Condition Trend Monitoring (ECTM) data
• Maintenance controller overworked with dual roles without appropriate support
• Inadequate Civil Aviation Safety Authority (CASA) auditing and oversight of operator's maintenance systems
• Informal arrangement for ECTM monitoring with Pratt & Whitney with no safeguards or follow-up mechanisms

Coroner's recommendations

1. CASA should rescind the Airworthiness Directive that allows time between overhauls to be extended based on manual ECTM systems and stipulate instead that such extensions can only be accessed when monitoring utilises automatic recording of engine parameters
2. CASA should review compliance with the relevant Airworthiness Directive and enhance auditing to give particular focus to adherence to ECTM procedures when overseeing operators permitted to extend time between overhauls
3. CASA should develop tools and guidance to assist field inspectors in assessing whether organisations have adequate maintenance resources and personnel, with particular attention to workload considerations when approving appointment of maintenance controllers and other key maintenance personnel