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' 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:
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.
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' 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.
Alliance Airlines flight crews were regularly changing the speed selector knob setting during the take‑off run. This was contrary to Embraer's guidance, and Alliance Airline’s own standard operating procedures manual. This increased the risk of distraction during a critical phase of flight.
Consistent with Embraer’s airplane operations manual, the Alliance Airline's pre-flight procedure required flight crew to unnecessarily initially set the speed knob to ‘manual’. This increased the risk of the aircraft departing with the incorrect speed mode selected.
Embraer's airplane operations manual was inconsistent with its standard operating procedures manual in relation to speed mode selection. This increased the risk of flight crews departing with the manual speed mode unintentionally selected.
Experience Co did not ensure sport parachutists received essential safety information about emergency exits, restraints and brace position, prior to take-off.
Regional Express did not provide flight crew or ground crew recurrent training to review the hand signals required to communicate with each other, including those used in an emergency.
Rex did not ensure its flight crews received training in the differences between passenger and freight‑configured Saab 340 aircraft, prior to being scheduled to fly freight operations.
The Pel-Air and Rex Saab 340 flight crew operating manuals did not include reference to the location and operation of the cross-valve handle or the operation and use of the smoke curtain.
Saab did not include the smoke curtain fitment in pre-flight documentation for the cargo‑configured Saab 340 aircraft to inform flight crew of this difference from the passenger‑configured version.
Australian states and territories that engage in Large Air Tanker (LAT) operations have developed their own separate standard operating procedures (SOPs) for LATs and aerial supervision assets. This can result in safety requirements being omitted or misunderstood by the different tasking agencies, such as a minimum drop height, resulting in inconsistencies in the development and application of LAT SOPs.
The Coulson Aviation crew resource management practice of limiting the pilot monitoring (PM) announcements to deviations outside the target retardant drop parameter tolerances increased the risk of the aircraft entering an unrecoverable state before the PM would alert the pilot flying.
Coulson Aviation and the relevant Western Australian Government Departments had not published a minimum retardant drop height in their respective operating procedures for large airtankers. Consequently, the co-pilot (pilot monitoring), who did not believe there was a minimum drop height, did not alert the aircraft captain (pilot flying) to a drop height deviation prior to the collision.
Coulson Aviation and the relevant Western Australian Government Departments had not published a minimum retardant drop height in their respective operating procedures for large airtankers. Consequently, the co-pilot (pilot monitoring), who did not believe there was a minimum drop height, did not alert the aircraft captain (pilot flying) to a drop height deviation prior to the collision.
The Coulson Aviation practice of recalculating the target retardant drop airspeed after a partial drop reduced the post-drop stall speed and energy‑height safety margins.
Likely due to an underlying lack of resources within Airservices Australia, there was an over‑reliance on tactical changes to manage the roster. As a result, cumulative fatigue was not being effectively managed strategically and an over‑reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.
Although Airservices Australia’s fatigue assessment and control tool (FACT) had the means of identifying situational factors that influenced fatigue, it had limited effectiveness as supervisors were not identifying low workload as a fatigue hazard.
