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Inquest

Summary

RESPONSE TO BUNGLE BUNGLE INQUEST FINDINGS

A Western Australian Coroner recently released findings into a 2008 fatal Robinson R44 Raven helicopter accident near Purnululu in the Bungle Bungle Ranges in Western Australia.  The findings highlight a number of safety concerns that require review by the aviation industry in relation the safety issues raised by the ATSB in its report released on 7 July 2010.

These issues cover:

  • Recovery from Low Main Rotor RPM;
  • Formalisation of Operator, Policies, Procedures and Practices

Circumstances of the accident

On 14 September 2008 a Robinson R44 Raven Helicopter, VH-RIO, crashed near Purnululu in the Bungle Bungle Ranges in Western Australia.  All four occupants were fatally injured.  The ATSB investigation advised that it was likely that due to the local conditions the helicopter was in a situation where the necessary engine power was either unavailable, or not fully utilised by the pilot, to sustain a hover.   The crash site indicated there had been significant main rotor RPM decay and a high rate of descent.

Safety Issues

The ATSB found the following safety issues as part of the investigation:

1. Recovery from Low Main Rotor RPM

There was no Australian requirement for endorsement and recurrent training conducted on Robinson Helicopter R22/R44 helicopters to specifically address preconditions for, recognition of, or recovery from, low main rotor RPM.

At the time of the release of the ATSB report, CASA had advised that it was reviewing the requirements for initial pilot training and endorsement and recurrent training on all helicopters, including a review of the Helicopter's Flight Instructor's Manual.

While noting that CASA was undertaking this review, the Coroner made a recommendation for CASA to address the safety issue raised by the ATSB.

In response to the safety issue CASA has advised the ATSB as follows:

"CASA is intending to produce an Instructor Pack for Awareness Training (AT) on the key hazards as specified in FAA SFAR 73.  This AT would be generic in nature, but would address specific discussion points on matters relevant to specific types, including but not limited to R22/R44."

2. Operator policy, procedures and practices

During the course of the investigation the ATSB also considered it necessary to draw the attention of all operators in the industry to the potential lack of assurance that informal operator supervisory and experienced-based policy, procedures and practices minimise the risk of their pilots operating outside the individual pilot's level of competence.

Operators were encouraged to take action where considered appropriate.

The ATSB continues to advocate that all operators in the industry should consider their procedures for appropriately tasking pilots.  Backing this, the Coroner noted the specific risks associated with low flight, including conducting aerial photography.

ATSB Investigations and Coronial Inquiries

Inquests are separate to ATSB investigations.  In this matter the respective authorities largely agree on what the safety issues are that the industry needs to take account of.

The ATSB's report can be downloaded by clicking on the link: AO-2008-062.  Feedback can be provided via the website.

The Coroner's report can be obtained from the Coroner's Court of Western Australia.  Contact details are available at: http://www.coronerscourt.wa.gov.au.  Queries regarding the Coroner's findings should be directed to the Coroner's Court of Western Australia.

 
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