Reopening the Park Pad in March 2022 created an increased risk of collision with traffic operating from the existing heliport. The conflict point was placed at a location where:
Sea World Helicopters is committed to simultaneous operation of helipads. It has determined that the risk of breakdown of separation at the conflict point is high and that high risk is tolerable. While the acceptance of risk brings the operator benefits, for passengers a flight from a single location would fulfill the same purpose without risk of breakdown of separation.
As the controls implemented rely on consistent conformance from people performing repetitive tasks, it is reasonable to expect those controls to fail at some point. Additionally, the risk will increase as frequency of flights increases. Therefore, the operator must continue to revisit controls and ensure the risk remains tolerable. Application of their safety management system to aviation safety risk, which was subject to a separate recommendation, will play a fundamental part in this ability.
Initial response by Sea World Helicopters
Sea World Helicopters made the following statement:
Reopening the park (overwater) pad reintroduced a known risk that was there in 2019 and for decades prior and had been operating for 9-months prior to the accident.
The operator stated that all associated risk with the change was managed by a group including:
…the only two pilots employed on a fulltime basis at that time plus the CEO [who was] a pilot and an examiner of airmen with 40+ years of flying experience around Australia including as Check Pilot at SWH under previous management.
The operator also proposed justifications for the limitations of the conflict point in the dot points below from the perspective of day-to-day operation at the helipad, rather than exploring alternatives from a design perspective. The operator assessment included:
The operator also obtained statements from experienced pilots who have flown both the EC130 and AS350 aircraft which state that with normal scanning techniques, both pilots involved in the accident flights would have had visibility of each other for the entire time. The operator also provided a video filmed from inside an EC130 at the park pad showing coordination with another company helicopter on approach to the heliport and keeping that helicopter in sight.
ATSB comment
The ATSB does not agree that because a conflict point existed in prior occasional operations that it should be accepted as-is and without formal analysis in newly developed operations by a different company. More so when the previous company was using additional controls to support pilots in managing separation. Safety analysis in the report explains these differences.
This safety issue highlights issues in the design of the conflict point. Not all intersections carry the same risks. A same level conflict point at 500 ft in cruise flight for example mitigates pilot workload and surface traffic concerns as well as improving traffic acquisition and making TCAS available.
In seeking to justify the existence of the conflict point in its current form, Sea World Helicopters assumes that traffic will always be visible, and pilots will never miss seeing other traffic if they just look, and the operator misses the point that all the dot points listed contribute to diminishing the ability of pilots to succeed in identifying and avoiding conflicting traffic that the design of the operation has committed them to.
The Australian Transport Safety Bureau recommends that Sea World Helicopters formally considers the design of conflict points within its operation and identifies opportunity for mitigation of risk, with a view to eliminating conflict points, or ensuring administrative controls give pilots the best opportunity to identify conflicting traffic and ensuring that the risk is as low as reasonably practicable.
As previously detailed, SWH management acknowledged and actively managed the flight conflict points identified after the appointment of the new CEO, circa December 2018/February 2019.
Flight conflict points within the CASA approved flight paths were and are the product of the existing physical location of both the Seaworld Theme Park, and other pre-existing environmental and strategically significant natural factors.
Post-accident the change of Chief Pilot, which is a Significant Change as per the CASR, required SWH to change its Exposition to be fully compliant with the new regulation which at the time were in a transition phase. The SWH AOC was never cancelled or restricted by CASA. This requirement meant that the entire exposition was rewritten and fully assessed by CASA as compliant.
Part of this assessment included the operational procedures detailed in the Base Operating Procedures which included the flight paths, loading and unloading procedures and operation of the Pad Boss.
CASA witnessed firsthand the operation on the ground during training and fully understood the flight paths. CASA had direct input with the maps in the Exposition showing conflict points and flight paths for each pad and operating direction and made suggestions regarding training and accreditation of the pad boss.
In addition to removing 4 conflict points after the appointment of the new CEO, since January 2023 SWH has initiated and actively adopted a new full-time Staff Position/Role of Pad Boss, to help mitigate the risks within the Take Off / Landing areas adjacent to the Broadwater.
The rational used was that with experienced and well trained pilots all with in excess of 1500hrs and all fully aware of the procedures and need to use normal scanning techniques that had been proven to ensure that visibility of the other aircraft in the area COULD be seen from any of the helicopters used by SWH that the conflict could be managed to avoid the incident that unfortunately and tragically occurred.
It is still and will always be the view of SWH that this accident would never have occurred if these procedures had been followed.
The Pad Boss role provides for:
1. Additional and independent visual check of the flight path prior to take off by Aircraft
2. Additional and independent audible check and confirmation of required pre-flight radio call by the PIC prior to take off.
3. Increased frequency requirement for SWH Pilot Check Rides from an annual check-ride to one check-ride at least every 9 months.
The operator provided evidence that they are committed to the configuration as it existed before the accident and are relying on continued successful operation of the pad boss role to mitigate the risk of midair collision between company helicopters. The operator did not provide evidence of any risk assessment or other such safety case for the conflict point. They reiterated their position that the pilots were responsible for the accident as they would have seen each other if they followed company procedures correctly.
CASA advised that their involvement with Sea World Helicopters was in issuing a Part 133 AOC after the midair collision. This work predated the final report, the safety issues, and the recommendations. The operator has taken no further action with respect to this recommendation and has not provided a risk document for the operation. The ATSB maintains that because this conflict point existed in prior temporary operations that it should not be accepted as-is and without formal analysis in newly developed operations by a different company. The operator has not addressed this recommendation and not demonstrated that the risk is a as low as reasonably practical.
SWH has considered the design of conflict points within its operation, and as has been previously advised, in fact reduced the overall number of those conflict points. All activities conducted by Sea World Helicopters focus on activity risk that is as low as reasonably practicable. Given that the organisation focusses on a culture of continuous improvement we agree with any opportunity to create new process or procedure that addresses the management of aviation safety risk.
SWH upon receiving an additional request for clarification from the ATSB on 12th August has re-assessed the specific Safety Finding. In doing so SWH has made further amendments.
What has been done:
Although SWH’s operations cannot eliminate conflict points due to the simultaneous operation of the Park Pad and Heliport, SWH has implemented controls for minimising aircraft operating at the same time near the conflict points identified in the Risk Assessment. The controls that restrict the ability for two aircraft to be operational at the same time near the identified conflict points include:
The risk controls include:
In addressing the risk of breakdown of separation at the conflict point, the operator also documented control measures of:
There is very little difference to a passenger, between departing on a flight from the main heliport or the park pad. A passenger will realise equivalent benefit from a flight from either location without exposure risk of collision at the conflict point if it was eliminated.
Sea World Helicopters stated that it is committed to the simultaneous operation of the helipads due to their strategic advantage. With the strategic value being related directly to revenue it can be inferred that the loss of revenue would be higher than the ongoing cost of the risk to the operator.
Sea World Helicopters has developed risk management plans and senior management have applied their own expert judgement to determine that their control measures have safety benefit and acceptable implementation costs.
Following application of control measures, the operator rates the residual risk of break down in separation at the conflict point as high. The operator’s risk management procedures, state that this is a tolerable level of risk requiring senior management attention and development of a risk mitigation plan. The risk mitigations rely on the role of ‘pad boss’. The pad boss is a traffic manager, and their role is intended to support the pilots in see and avoid.
It is reasonably foreseeable that risk of collision at the conflict point will increase over time and that continued vigilance on the part of Sea World Helicopters is required to maintain the integrity of the control measures it has developed.
The control measures are mainly administrative controls. Administrative controls can be useful but do not change the nature of a risk. They rely on people to consistently conform in the behaviour and should be expected to fail at various times.
For example, a sterile cockpit modifies the effectiveness of other controls that require pilots to make and receive calls by keeping the cabin quiet. The control relies on passengers following instructions to remain quiet or pilots to isolate their intercom below 500ft. It is reasonably foreseeable that not all passengers will understand instructions to be quiet during an exciting flight, and pilots might not always isolate passengers.
There is also risk of behavioural adaptations to control measures reducing the effectiveness of others. For example, pilots could come to rely on the airspace information and clearance provided by the pad boss and reduce their own visual scan. Indeed, the ATSB observed a pilot depart the park pad with sole reference to the pad boss and without clearing airspace. This was discussed with the head of flight operations at the time of observation.
At the time of the accident the operator was conducting around 7,500 flights per year. Their predecessor was conducting over 18,000 flights per year (in a different configuration). This shows scope for expansion of the business, and with it increase in risk. As the risk is related to pairs of helicopters, if the frequency of flights doubles the number of potential conflict pairs will quadruple.
The operator must then continually reinforce controls and revisit their assessments to ensure that the risk remains tolerable to them. Focusing their safety management system on aviation safety risk, which was subject to a separate recommendation, will play a fundamental part in this ability.
