The Australian Transport Safety Bureau has released an interim report detailing contextual information established as part of its ongoing investigation into the mid-air collision between two helicopters on the Gold Coast one year ago.
The report is intended to update the industry and public on the progress of the ATSB’s independent ‘no blame’ investigation, which is conducted with the goal of improving transport safety.
“To date, the ATSB has undertaken extensive work to understand and recreate the events of the day in order to identify and examine the context and risk controls that existed at the time,” Chief Commissioner Angus Mitchell said.
“The ATSB analysis framework looks at a hierarchy of factors arranged in their relative proximity to an event, and this investigation has so far concentrated on elements closest to the event: individual actions, vehicle/equipment performance, local conditions, and risk controls.”
This work has included interviews with key personnel and witnesses, the examination of both helicopters, maintenance logs, and postmortem information, a review of industry understanding of seat belt fitment, and analysis of ADS-B and radar flight tracking information, CTAF recordings, and video imagery.
“A large amount of the evidence gathered through this work is detailed in today’s interim report, and investigation into and analysis of many of these areas is ongoing,” Mr Mitchell said.
Mr Mitchell noted the evidence includes a toxicology report for the fatally injured pilot, showing a positive result for low levels of cocaine metabolites.
“A forensic pharmacologist engaged by the ATSB has stated that the very low concentrations of these metabolites suggest exposure was not likely to have occurred in the 24 hours prior to the accident, and it is unlikely there would have been impairment of the pilot’s psychomotor skills,” he said.
“It is important to note while this is a substantive and comprehensive interim report, the ATSB is yet to make formal findings as to the contributing factors that led to this accident as we are continuing our analysis of that evidence.”
Moving forward, Mr Mitchell said the investigation would consider whether any systemic factors contributed to, or increased risk in the accident.
“This will include consideration of the design of the operating environment and operating procedures, the onboarding and implementation of aircraft, change management, and the regulatory environment and input,” he explained.
The ATSB’s final report, which will include analysis, findings, and any recommended safety actions, is on track for an anticipated completion in the third quarter of 2024.
“This was a tragic accident, and it is our responsibility to make findings and drive safety actions, which reduce the likelihood of a similar occurrence in the future,” Mr Mitchell said.
The interim report notes several steps which have already been taken in response to the accident.
After reviewing its processes and procedures, Sea World Helicopters has implemented a new ‘pad boss’ traffic advisory role, added air traffic systems to each of its helicopters’ avionic systems, increased communication protocols, and taken steps to make its helicopters more visible.
Separately, the ATSB issued a Safety Advisory Notice in September, targeting aircraft lifejacket manufacturers and national aviation certification authorities.
“During this investigation, our investigators identified a potentially common lack of understanding in the broader helicopter tourism community about how constant wear lifejackets should be worn in conjunction with seatbelts,” Mr Mitchell explained.
“This correlated with a discovery that some passengers’ seatbelts were not fitted correctly in this accident, in part due to interference from their lifejackets – although we have not attributed this to the tragic outcomes in this case.”