Operator risk management
Date issue released
Safety Issue Description

The operator's hazard and risk register, which formed part of the organisation's safety management system, did not identify inadvertent entry into instrument meteorological conditions as a hazard, which reduced the ability of the organisation to effectively manage the related risk.

Issue number
Issue Status
Open – Safety action pending
Transport Function
Aviation: Air transport
Issue Owner
Executive Helicopters
Mode of Transport
Issue Status Justification

The ATSB acknowledges the safety action taken by Executive Helicopters to reduce the risk of inadvertent entry into IMC. The ATSB considers that, once implemented, the proposed safety action will address the safety issue.

Proactive action
Action number
Executive Helicopters
Action Status
Action description

In August 2023, Executive Helicopters advised that they had removed fixed wing operations from their Air Operator's Certificate (AOC) and had updated the hazard register to include inadvertent entry into instrument meteorological conditions (IMC) as a hazard. A risk assessment was conducted with controls introduced to minimise the risk to helicopter operations, with a focus on pilots avoiding IMC. Pilots are being educated about the necessity to remain visual at all times, and on the visual meteorological condition (VMC) requirements. If pilots assess that they are unable to maintain VMC, they are encouraged to slow down and either land until the weather improves or return to a safe landing site.

In November 2023, Executive Helicopters advised of 2 additional changes planned to be implemented by February 2024. The operations manual will be updated to include a formal organisational policy explicitly supporting a pilots’ decision to land or return to a safe landing site if they assess that they will be unable to maintain VMC. The annual operator proficiency check will also have an additional item covering avoidance of inadvertent entry into IMC and recovery techniques, including a pre-flight briefing and in-flight recovery techniques to be flown during the check flight. The pre-flight briefing will include a discussion of:

  • VMC requirements
  • the importance of maintaining VMC at all times
  • the likely consequences of inadvertent IMC
  • company policy to land and notify management when faced with inclement weather
  • slowing down in reduced visibility
  • using maps and charts to avoid high terrain and structures
  • recovery techniques in both cloud and smoke.

The proposed in-flight recovery techniques to be flown are:

  • in cloud – look behind for visual horizon, if not available then maintain attitude, ensure constant altitude and conduct a rate one, 180° turn
  • in smoke at low level – hold wings level, maintain constant heading and commence a gentle climb.
ATSB Response

The ATSB understands that since aeroplane operations have been removed from the AOC, any safety action must be considered within the context of helicopter operations.

The ATSB welcomes the updated hazard register and risk assessment, and associated controls, noting that the organisation formally supports prudent pilot decision making regarding weather and adherence to the controls. In particular, the addition of a theoretical and practical inadvertent IMC component to the annual operator proficiency check should reinforce the knowledge necessary to assist pilots in avoiding inadvertent entry into IMC, while also providing skills in recovery from an inadvertent IMC encounter. Adherence to the organisational policy, and the piloting skills gained during the operator’s annual proficiency checks should reduce the risk associated with inadvertent IMC encounters.

The ATSB will monitor the progress of the proposed safety actions and re-assess the safety issue once they are implemented.