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' 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' 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' 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:
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.
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.
The South Australian Passenger Transport Authority approved a package of inspection and test plan procedures that did not specify any requirement for tests to verify and validate the safety integrity of the altered level crossing control circuits. The effectiveness of inspection and test plan procedure to control risk and provide assurance the signalling system functioned safety for trains operating on the ARTC network relied solely on the methodology adopted by the subcontracted signal team on the day.
Documentation supporting the training and competency assessment of launch coxswains was limited in detail and training records were incomplete.
The safety management system for Corsair did not include detailed guidance and reference material for the safe navigation of Port Phillip Heads, the effective use of launch navigational equipment and the role of the launch deckhand in supporting safe navigation.
The ship's managers' (CMA CGM) safety management system procedures and guidance for steering gear operation across its fleet were ambiguous and did not clarify the different terminology to those commonly used by the industry. This increased the risk of incorrect configuration of the steering gear, which occurred on board CMA CGM Puccini.
Maritime Safety Queensland and Poseidon Sea Pilots did not have a process to jointly and effectively identify and risk assess the hazards to shipping and pilotage that were outside normal environmental conditions.
The Pilbara Ports Authority's port user guidelines and procedures did not reflect the best practice escort towage guidance detailed in the port's draft escort towage strategy and business continuity plan. The detail of these improved towage practices, designed to reduce the risk of channel blockages, were also not integrated into the Port Hedland Pilots' safety management system and were consequently, inconsistently applied by pilots.
Although Hagen Oldendorff’s steering and rudder angle indicator systems complied with the applicable rules and regulations, neither the SOLAS regulations, nor the rules of the ship’s responsible classification society, Lloyd’s Register, mandated protection of the ship's rudder angle indication systems against a single point of failure in power supply, nor did they require installation of audible or visual alerts to notify the bridge team of a power failure affecting the indicators.
Although Hagen Oldendorff’s steering and rudder angle indicator systems complied with the applicable rules and regulations, neither the SOLAS regulations, nor the rules of the ship’s responsible classification society, Lloyd’s Register, mandated protection of the ship's rudder angle indication systems against a single point of failure in power supply, nor did they require installation of audible or visual alerts to notify the bridge team of a power failure affecting the indicators.
Although Hagen Oldendorff’s steering and rudder angle indicator systems complied with the applicable rules and regulations, neither the SOLAS regulations, nor the rules of the ship’s responsible classification society, Lloyd’s Register, mandated protection of the ship's rudder angle indication systems against a single point of failure in power supply, nor did they require installation of audible or visual alerts to notify the bridge team of a power failure affecting the indicators.
The Pilbara Ports Authority's port user guidelines and procedures did not reflect the best practice escort towage guidance detailed in the port's draft escort towage strategy and business continuity plan. The details of these improved towage practices, designed to reduce the risk of channel blockages, were also not integrated into the Port Hedland Pilots' safety management system and were, consequently, inconsistently applied by pilots.
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.
