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Lack of formalised monitoring role

Issue number: AO-2009-004-SI-02
Who it affects: Helicopter operator
Issue owner: Helicopter operator
Operation affected: Aviation: General aviation
Background: Investigation Report AO-2009-004
Date: 05 October 2010

Safety issue description

The lack of formalised procedures in place requiring the Air Crew Officer (ACO) to monitor key instrument indications probably contributed to the undetected altitude loss.

Proactive Action

Action organisation: Emergency Management Queensland Helicopter Rescue
Action number: AO-2009-004-NSA-023
Date: 05 October 2010
Action status: Closed

Shortly after this occurrence, the operator issued a safety bulletin to all flight crews emphasising the importance of effective crew resource management (CRM) during all phases of normal and emergency flight. This was followed by the development of crew standard operating procedures that were implemented at all of the operator’s bases via a standards directive on 3 July 2009. Those procedures formalised the duties and responsibilities of the air crew officer while occupying the front left seat, including the monitoring of flight tolerances and provision of alerts to the pilot.

The directive also detailed the introduction of sterile cockpit procedures and altitude management procedures relating to setting and monitoring the helicopter’s barometric and radio altimeters. The operator also indicated that they intended to utilise this event in future CRM training.

ATSB response:

The ATSB is satisfied that the action taken by the helicopter operator adequately addresses the safety issue.

   
Current issue status: Adequately addressed
Status justification:

CRM aspects addressed

 
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Last update 28 February 2014