An ATSB investigation of coordination and communication issues between firefighting aircraft near the NSW-Qld border on 31 October 2023 has led to extensive, systemic safety improvements.
The incidents occurred when up to 18 smaller NSW Rural Fire Service (RFS) aircraft were operating over multiple firegrounds in the Tenterfield region, and the state operations controller proactively dispatched three large air tankers (LATs) and their lead plane (known as a birddog) to the area.
The ATSB’s investigation found these new assets were dispatched without a target and without first coordinating with the local incident management team.
Further, the investigation found the NSW RFS did not have a procedure for ensuring the tasking of LATs by the state air desk would be coordinated with the incident management team, so the large assets could be integrated into the existing incident plan.
“It was likely the state operations controller had assumed the LATs would be coordinated by the local air attack supervisor, who was in a helicopter,” ATSB Chief Commissioner Angus Mitchell said.
“But this air attack supervisor was not actually aware the LATs were inbound, and was just about to leave the fireground for fuel when the LATs arrived unexpectedly. The air attack supervisor subsequently did not provide traffic or local radio information to the birddog crew.”
The crews of the LATs and the birddog were then unable to communicate and coordinate with other aircraft in the area, and reported coming into unsafe proximity with other aircraft several times.
The ATSB’s final report details findings relating to the NSW RFS’s aerial asset coordination, including the expectations placed on local air attack supervisors.
“The NSW RFS procedure required an air attack supervisor when three or more aircraft were deployed to a fireground, but there was no assurance aerial supervision would remain adequate as the size of the fire or aircraft numbers scaled up,” Mr Mitchell said.
Compounding the situation on the day of the incidents, Queensland Fire Department (QFD) also had aerial assets at an adjacent fireground on the NSW-Qld border.
“Neither the NSW RFS nor QFD had established cross-border coordination procedures for aerial firefighting activities to ensure reliable aircraft communication and separation,” Mr Mitchell said.
The report notes the NSW RFS has introduced “extensive systemic-level safety improvements” in response to the identified safety issues, including a new policy to ensure LAT pilots receive a briefing from the incident management team regarding incident strategy prior to departure.
There are also new procedures for state air desk and incident management team liaison, regular assessments of operational complexity and the number of aircraft deployed to a fireground, the implementation of temporary restricted areas, and the allocation of fire-specific radio frequencies.
In addition, in January 2024 the National Aerial Firefighting Centre released the national cross-border airspace management guideline, which establishes coordination measures between different jurisdictions, including procedures for frequency alignment, and liaisons between state air desks.
Mr Mitchell welcomed the safety actions taken, noting all seven of the investigation’s identified safety issues had been adequately addressed.
“Aerial firefighting is a critical capability for the management and suppression of bushfires in Australia,” he said.
“As the number of LATs and other aerial assets being used for firefighting increases, it is important that operators, tasking agencies and other relevant parties continue to develop and improve their safety systems to mitigate risk.”
Mr Mitchell noted this investigation was the third undertaken by the ATSB involving LATs, following that into the loss of a 737 air tanker in WA in 2023, and the fatal accident involving a C-130 air tanker in NSW in 2020.
“During aerial firefighting operations, non-standard procedures and practices may result in unforeseen risks emerging,” he said.
“It is therefore critically important for tasking agencies to take the lead, with the support of stakeholders, in developing the quality and safety standards they require for the firefighting effort to mitigate operational risks.”
Read the final report: Coordination and communication breakdown during aerial firefighting operations, near Tenterfield, New South Wales,on 31 October 2023