Coulson Aviation's safety risk management processes did not adequately manage the risks associated with large air tanker operations. There were no operational risk assessments conducted or a risk register maintained. Further, as safety incident reports submitted were mainly related to maintenance issues, operational risks were less likely to be considered or monitored. Overall, this limited their ability to identify and implement mitigations to manage the risks associated with their aerial firefighting operations.
As a result of this investigation, on 3 August 2022, Coulson Aviation advised the ATSB that:
Numerous enhancements have been made to the Coulson Group SMS, and these continue to be developed and improved. The three-tier risk management approach of organisational risk, operational risk and tactical/mission risk will be utilised during the upcoming fire season in Australia.
The ATSB welcomes Coulson Aviation’s safety action, and recognises that it takes time to develop and implement these aspects within a safety management system. The ATSB will monitor the progress of these developments.