Operator’s hazard identification processes
Date issue released
Safety Issue Description

Although the operator’s safety management processes were improving, its processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations.

Issue number
Transport Function
Aviation: Air transport
Issue Owner
Pel-Air Aviation
Mode of Transport
Issue Status Justification

The ATSB is satisfied the safety action undertaken by the operator to improve its hazard identification processes following the November 2009 accident reduced the risk of this safety issue.

Proactive action
Action number
Pel-Air Aviation
Action date
Action Status
Action description

After the accident, the operator undertook a detailed review of its air ambulance operation and the associated risk controls. In addition, it conducted a series of actions to improve its hazard identification processes. These included:

  • conducted a workshop with a sample of the operator’s managers and flight crew (across all fleets) to identify fatigue hazards and risk controls
  • implemented an internal audit schedule that focussed on the actions introduced following the 18 November 2009 accident (including audits of fuel policy and fuel planning, FRMS, operational support provided to flight crew, training and checking and defect reporting during January to March 2010)
  • provided additional training on the operator’s SMS to all Westwind pilots.

In October 2017, the operator advised the ATSB:

In addition to the actions already contained in the report, significant change has occurred within Pel-Air in relation to Hazard Identification. Pel-Air’s Safety Management System today is more sophisticated, mature and robust and Pel-Air is more proactive in identifying and assessing hazards and risks.

Pel-Air achieved and has held Flight Safety Foundation - BARS Program Gold registration standard since 2013 and the Executive Summary of the last and recent Audit Report includes the following in relation to Quality and Safety Management;

Pel-Air utilises the Group’s Quality Assurance and Safety Management structure that has direct communication with senior management and regular safety meetings and safety related bulletins ensure dissemination of all safety related information.

The company demonstrated there is a strong Safety Management System, Quality Assurance and Control Systems and that it has a dedicated commitment to hazard and occurrence reporting. All of which are signs of a mature and robust organizational structure.

Pel-Air has also received similar comments from other external auditing organisations.

As advised in relation to Safety Issue [AO-2014-190-SI-07], in 2010, formal Change Management policy and procedure was also implemented across the Rex Group of Companies as part of our Group Safety Management System and Manual chapter 6… which particularly includes the need to identify and consider new hazards as a result of constant change.

This has been an integral part of all Rex Group business units ever since.

The Rex Group’s risk management framework and principles of risk management are based on ICAO Annex 19- Safety Management and the associated Safety Management Manual (Doc 9859), the International Standard ISO 31000: 2009 Risk Management- Principles and Guidelines, and the Australian Transport Safety Bureau (ATSB) Safety Investigation Guidelines- Risk Analysis:2011.

Some specific examples of the Group risk and change management policies being followed within Pel-Air since the accident have been;

▸Formal Change Management Plan for the Westwind and Learjet operation moving from defence activities to civilian operations.

Development of a specific set of procedures and processes for the jet operation in Malaysia which were subsequently published in Part C of the Operations Manual.

Formal Risk Assessment to change to aircraft based checks in the Jet operation.

Formal Risk Assessment for the introduction of APG performance data and charts.

Formal Risk Assessment for night operations to certain Authorised Landing Areas...

Formal Risk Assessment for duties that involve flight across numerous time zones.

Numerous formal Risk Assessments for dispatch of international flights to Manus Island, Christmas Island, Papua New Guinea and Wake Island.

Formal Risk Assessment prior to operating the B200 King Air on narrow runways.

▸These processes are constantly reviewed and, for example, Change Management processes were further bolstered in June 2015 as part of the approval process for Rex to obtain an Area AOC.

▸Event Categories and Causal Factors have also since been introduced from investigation and audit findings which further assists with predictive analysis.

▸Hazard Identification and the Safety Management System was also a feature article in the August 2017 edition of the Group Safety Newsletter.