Wave Air's weight and balance system used an incorrect empty weight moment arm to calculate the aircraft's centre of gravity, and passengers were not weighed in accordance with their procedures.
The training, supervision and checking flights conducted by Wave Air did not identify that an excessive approach speed was routinely being used by the pilot during the final approach to land.
The decision height for assessing whether an aircraft met Wave Air’s stabilised approach criteria was too low.
Broome Aviation pilots experienced pressure not to report aircraft defects on maintenance releases, and many pilots also experienced or observed pressure from individuals within the company management to conduct flights in aircraft with defects that they considered made the aircraft unsafe for flight.
During the 8-month period from November 2022 until the accident, Broome Aviation provided its pilots transitioning to operating the Cessna 310 with limited supervision, guidance and support, including management of the fuel system.
Broome Aviation’s operations manual did not include a procedure for recording inflight fuel calculations. As a result, pilots adopted varying methods for fuel monitoring, leading to reduced assurance of accurate fuel management.
Aircraft defects were not written on the maintenance release, leading to several defects not being rectified or managed.
ARTC’s systems for management of track lateral stability did not lead to identification of the location as a special location potentially vulnerable to track instability.
Sea World Helicopters was reliant on CTAF calls, ground crew advice, and pilot visual detection of aircraft to ensure separation in VH-XH9 and VH-XKQ. Available additional controls for enhancing alerted see-and-avoid and reducing the risk of collision were not implemented.
Response by Sea World Helicopters
Sea World Helicopters provided the following response:
SWH state that additional controls for alerted See and Avoid were available.
Sea World Helicopters' documented procedures for communication between inbound and outbound helicopters were not specific to their usual operation and location, and permitted a reactive model of separation, increasing the likelihood that an outbound pilot would not form awareness of relevant traffic. While some company pilots made proactive calls during final approach, this was not a standard practice.
Response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
Sea World Helicopters' procedure did not require ground crew to monitor the airspace up to the time of the helicopter departing the helipad. As the presence of hazards behind the helicopter could change significantly within a short space of time, helicopters routinely departed without current hazard information from ground crew.
Sea World Helicopters' standard inbound call from Porpoise Point was not a reliable alert for a pilot on the ground while boarding and interacting with passengers. Where collision risk on departure existed, a pilot on the ground would highly likely be focused on cabin preparation at the time of that inbound call.
Sea World Helicopters' implementation of their SMS did not effectively manage aviation safety risk in the context of the operator's primary business. Additionally, their objectives were non-specific, and the focus of safety management was primarily ground handling and WHS issues. This limited the operator's ability to ensure that aviation safety risk was as low as reasonably practicable.
Response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
Sea World Helicopters commenced operations with EC130 helicopters without a formal change management process. Implementation of the operator's documented procedures would have increased the likelihood of formal consideration of various risk controls, including controls that were previously applied for the introduction of aircraft.
Response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
Reopening the Park Pad in March 2022 created an increased risk of collision with traffic operating from the existing heliport. The conflict point was placed at a location where:
Sea World Helicopters' change management process, conducted prior to reopening the park pad, did not encompass the impact of the change on the operator's existing scenic flight operations. Crucially, the flight paths and the conflict point they created were not formally examined, therefore limitations of the operator’s controls for that location were not identified.
Response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
At the time of park pad assessment, the Civil Aviation Safety Authority's guidance documents for establishment of helipads did not prompt assessment of flight path interaction with other already established traffic.
Sea World Helicopters did not have documented procedures or guidance on the correct fitment of aircraft seatbelts in conjunction with constant wear lifejackets. As a result, on the job training provided to ground crew included incorrect fitting practices, leading to passengers being routinely incorrectly restrained. This increased the risk of injury to passengers in the event of an accident.
Sea World Helicopters' passenger safety briefing system, comprising of a passenger safety briefing video supplemented by safety cards and ground crew advice had limited, inconsistent and incorrect information about correct fitment of seatbelts, location and emergency operation of the EC130 doors, and the emergency brace position.
Following the change in ownership of Sea World Helicopters, changes to the operation gradually degraded existing controls of enhanced communication and in-cockpit traffic display that informed team situation awareness, and the controls were eventually withheld without formal analysis of the change. This reduced opportunity for company pilots to form and maintain awareness of each other's position and intentions.
