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.
Coulson Aviation has updated its safety risk management processes, including the development of a risk register, risk profiles and operational risk assessments for its large air tanker operations. The ATSB is satisfied that the effective implementation of the safety management system will reduce the risk of the identified safety issue. As such, the ATSB will close the safety issue as adequately addressed.
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.
Coulson Aviation's Safety Management System (SMS) Manual has been updated, which outlines the organisation’s closed-loop safety risk management framework. This details how risks are proactively identified, characterised, mitigated, and continuously monitored across all operational domains.
Additionally, the SMS outlines the development and use of our Core and Operational Risk Profiles. These profiles are designed to work in conjunction with the Flight and Ground Risk Analysis Tools (FRAT and GRAT), ensuring that risk assessments remain dynamic, operationally relevant, and embedded in daily decision-making processes. The FRAT and GRAT are completed each day in the electronic SMS prior to the first flight or maintenance activity, and again whenever mission or tasking parameters change.
In terms of regulatory alignment, the SMS has been reviewed and accepted by CASA.
The ATSB recognises the development and implementation of risk management improvements to the SMS, including the development of a risk register, operational risk profiles and risk assessments. Well-implemented SMS are associated with enhanced safety performance, and these formalised processes, when effectively utilised by all personnel, should reduce the risk of the identified safety issue.
