Inquest into the Death of Jandakot Aircrash

Contributing factors

• Engine-driven fuel pump failure due to galling of sleeve bearing
• Incorrect material specification (aluminium bronze instead of high-leaded bronze) in engineering order EO6826/1
• Lack of metallurgical assessment during engineering design process
• Inadequate CASA oversight of CAR 35 authorised persons and CAR 30 design organisations
• Deficient audit procedures for Aeronautical Engineers Australia
• Absence of clear communication of engineering order requirements to aircraft operator and pilot
• Aircraft near maximum takeoff weight for aerial work classification
• Pilot decision to turn left to avoid high-voltage power lines, degrading aircraft performance on one engine
• Insufficient time allowed for aircraft to climb after engine failure
• Lack of immediate aerodrome rescue and fire fighting service (ARFFS) at Jandakot Airport

Coroner's recommendations

1. CASA ensure reasonably comprehensive audits of all CAR 30 organisations and CAR 35 authorised persons at no more than 24 month intervals
2. CASA require CAR 30 design organisations and CAR 35 authorised persons to ensure engineering orders contain sufficient information indicating basis of order and whether proposing like-for-like replacement or new item; metallurgical reports required for material changes
3. CASA consider withdrawing CAR 35 delegation or preventing persons/organisations from continuing to exercise functions if engineering orders lack sufficient information
4. CASA propose increase in operations classification and minimum safety standards for organisations regularly transporting employees and similar personnel
5. Western Power affix orange aviation balls to high-voltage power lines near normal flight paths of Jandakot Airport
6. CASA review process for issuing engineering orders to ensure aircraft owners, operators and maintainers receive copies regardless of who commissioned the order
7. Jandakot Airport Holdings acquaint staff with emergency plan and ensure appropriate response capability
8. Jandakot Airport Holdings, Western Australia Police, Airservices Australia and FESA organise regular exercises for emergency response coordination
9. All Western Australia Police officers at Murdoch Police Station familiarised with Jandakot Airport emergency plan and undertake airport orientation
10. Jandakot Airport Holdings, Airservices Australia and Western Australia Police develop protocol for major incidents addressing runway closure obligations
11. Review Jandakot Airport Emergency Plan, State Air Crash Emergency Management Plan and Airservices Australia Emergency Management Plan to ensure immediate runway access for emergency vehicles, clearly identified Incident Controller prior to police arrival, and clear handover procedures
12. RFDS be supported in requests for improvements to facilities at Jandakot Airport
13. Ongoing communication between Airservices Australia and Jandakot Airport Holdings regarding fast incident response capability including possible low-cost emergency fire response system
14. CASA review quality of airport emergency plans for major general aviation airports to ensure immediate response capability and clear incident control procedures
15. Minister issue charter letter directing CASA to allocate greater priority to general aviation safety issues to significantly reduce fatalities