Aviation safety issues and actions


Issue number: AO-2008-078-SI-03
Who it affects: The helicopter owner
Issue owner: The helicopter owner
Transport function: Aviation: General aviation
Background: Investigation Report AO-2008-078
Issue release date: 09 December 2010
Current issue status: Adequately addressed
Issue status justification:

The operator has introduced a number of changes to address the safety issue.

Safety issue description

There was no direct supervision of the joint testing operations.

Proactive Action

Action number: AO-2008-078-NSA-141
Action organisation: Helicopter owner
Action status: Closed

Immediately following the occurrence, the helicopter operator halted all platform operations and commenced a review of operations. That included reviewing the procedures for joint testing, having an independent auditor review the company’s operations, and having the chief pilot of one of the industry leaders in the field visit from the US and review the operation.

On 2 November 2009, the operator advised that:

The following items which have been introduced at [the operator] since the November 2008 accident (VH-PLJ):

  • Initially discontinued all platform work until internally satisfied that the company was ready to safely resume.
  • Appointed a Safety Manager (WHSO).
  • Safety Manager undertakes Qld OH&S Training courses.
  • Appoint a Training Manager.
  • Appoint a Senior Manager to [the operator’s] Management team General Manager- Aviation. (Company structure reviewed).
  • Enforced the role of the Safety Observer (Pilot and Linesman).
  • Introduced new training programs:
    • Electrical theory for pilots, which now starts at the insulator washing level practical and written test.
    • New, more detailed presentation for platform workers (pilots and line workers), which covers many more subjects.
    • Several new training topics have been developed which are to be introduced at the training week.
    • On the job training task specific which includes both practical and written test for the pilots.
  •  [The helicopter operator] Staff attend the “CRM Wire Environment Training Course Australia wide”.
  • Gathered US powerline accident information into a booklet for staff to learn from.
  • A full training week scheduled for all staff and invitee. November 30th 2009.
  • Updated and upgraded company Work Instructions to a new format which is more detailed and better highlights caution and warning points and includes detailed risk assessments. Initial upgraded focused on Platform procedures WI 611/01, 02 05, 06, and 22.
  • More emphasis on internal auditing and increase the frequency, audit training course conducted for senior [helicopter operator] management staff.
  • Created a comprehensive company Risk Management register. Relevant extracts are placed into the work procedures which are at every job site.
  • Created a Incident and Accident register to learn of trends etc and used as a training aid.
  • Appoint Third Party Pilot to conduct flight training of all [of the helicopter operator’s] pilots (general flight review).
  • Platform work approval to recommence September 2009.
  • Designated specific trainers for specific training topics/tasks.
  • Compliance to AS9001:2008 November 2008.
  • Third party consultant employed to obtain “Company Compliance to NSW OH&S”, which will be the model for the future National OH&S 4801 March 2009.
  • Review of [Fatigue Risk Management System] FRMS system, new system developed and sent to CASA. Removal of [Fatigue Audit InterDyne®] FAID which is not suitable for our operation. Revised FRMS is built under the recommended of “prior sleep wake rule”. (Awaiting approval CASA). Currently on CAO 48 [Flight Time Limitations].
  • Implementation of new “Emergency Response Plan” Handbook.
  • Implementation of CASA [Drug and Alcohol Management Plans] DAMP policy.

ATSB comment:

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

Last update 11 February 2014