Safety issue
| Safety issue description |
The lack of formalised procedures in place requiring the Air Crew Officer (ACO) to monitor key instrument indications probably contributed to the undetected altitude loss. |
|---|---|
| Issue number | AO-2009-004-SI-02 |
| Issue owner | Helicopter operator |
| Transport function | Aviation: General aviation |
| Date issue released | 05/10/2010 |
| Issue status justification |
CRM aspects addressed |
Safety action
| Action type | Proactive action |
|---|---|
| Action number | AO-2009-004-NSA-023 |
| Organisation | Emergency Management Queensland Helicopter Rescue |
| Action date | 05/10/2010 |
| Action description |
Shortly after this occurrence, the operator issued a safety bulletin to all flight crews emphasising the importance of effective crew resource management (CRM) during all phases of normal and emergency flight. This was followed by the development of crew standard operating procedures that were implemented at all of the operator’s bases via a standards directive on 3 July 2009. Those procedures formalised the duties and responsibilities of the air crew officer while occupying the front left seat, including the monitoring of flight tolerances and provision of alerts to the pilot. The directive also detailed the introduction of sterile cockpit procedures and altitude management procedures relating to setting and monitoring the helicopter’s barometric and radio altimeters. The operator also indicated that they intended to utilise this event in future CRM training. |
| ATSB response |
The ATSB is satisfied that the action taken by the helicopter operator adequately addresses the safety issue. |
| Action status | Closed |