Sea World Helicopters' implementation of their SMS did not effectively manage aviation safety risk in the context of the operator's primary business. Additionally, their objectives were non-specific, and the focus of safety management was primarily ground handling and WHS issues. This limited the operator's ability to ensure that aviation safety risk was as low as reasonably practicable.
The Sea World Helicopters' aviation SMS has improved the direction around its objectives and has taken steps to improve reporting concerning aviation safety risk. However, an opportunity is missed by not designing objectives focussed on Sea World Helicopters' unique operation. Given the reasonably foreseeable risk in the operation, the further development of the SMS will be vital to detecting and managing changes in risk profile to ensure continued success.
Initial response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
Prior to Dec 2018, the PHS [professional helicopter services] management team gave a presentation to the then current staff of SWH where we stressed the importance… of Safety. It was part of our Vision and our Ethos, and we were bringing that to SWH.
It detailed our Vision to be recognized as Australia’s safest and most enjoyable helicopter tourism company and our Ethos – Safety is the foundation of what we do. Experience and enjoyment are the outcomes. These were our objectives, they are clear, concise and were published.
From the outset changes were made, in consultation with both the Chief Pilot and Safety Manager, this included changing flight paths and the building of the facility to improve safety, not only on the ground but for the movement of aircraft in all phases of flight.
Improving safety was the primary reason for making these changes.
Sea World Helicopters also stated that the ATSB had:
…continuously ignored the effects of COVID-19 and its effects throughout the world and the health issues that had to be dealt with in the SWH business. Comparing flight incident report numbers from year to year but ignoring the numbers of flights as a contributing factor. Total flights in 2019 were 20,054 and the total flights for 2020/2021 were 7195 (an average of 9 per day). In 2020 and 2021 the company operated mostly with just one pilot, that pilot was the HOFO/HAAMC.
Passenger numbers and staffing numbers decreased along with risks to report. At one point the office closed for three months. When flights did occur the passenger demographic was totally different to pre-COVID. The passengers prior to Jan 2020 were 80% Chinese Mainland groups, nearly all of whom, did not speak English. These tourist groups are yet to return to Australia.
And:
…we find the last 7 months prior to the accident, the safety management in this period is ignored as a subject by the ATSB. The amount of incident reports increased, there were more safety meetings and briefings about safety meetings in a period of time than we can find recorded for the period before Dec 2018.
In response to this finding the operator also states:
When at work the SWH team were encouraged to work as only a small team can, there was a safety suggestion box put in the team’s breakout room for them to provide any type of safety feedback, including anonymously. Minor items were done on the spot where possible. Items relating to flight safety whilst sought did not arrive as for these two years there was between one and two pilots only.
In addition to the Safety Manager, we employed a Quality, Safety & Compliance Officer, who although part-time, attended all weekly management meetings. Assistance was still provided by the PHS Safety Manager in matters of compliance and documentation.
SWH thoroughly believes it manages risk and the safety of its staff and customers very well.
ATSB comment
The operator’s response to the finding does not address effective engagement with aviation safety risk. The aspirational vision of the company did not translate into defined objectives of the safety management system. As discussed in the report in Safety policy and objectives, the objectives of an SMS are intended to be practical achievable goals.
The effect of COVID-19 was discussed in the report in the Disruption due to global pandemicsection. Following draft review, the operator provided flight numbers which have been used to normalise reporting by flight hours to account for the lower activity during COVID-19. Flight operation reports were shown to reduce after the change of ownership while WHS reporting did not, and did not recover after the pandemic.
The 7 months of SMS prior to the accident were covered in detail in various places within the Safety management section. The report related the success of the operator’s SMS in that period in managing ground handling and WHS matters. While WHS is a very important and legislated element, as stated in CASA guidelines, an aircraft operator’s SMS should concentrate on aviation safety risk.
The operator’s primary business was high frequency low duration helicopter flights from 2 nearby helipad facilities. The report agrees that the changes made were intended to improve safety, but as the SMS was not focused on aviation safety risk, processes which could have contained unintended consequences of those changes were not used.
The operator has not so far provided evidence of defining safety objectives and support for ongoing engagement with aviation safety risk, and is therefore still at risk of being limited in its ability to ensure that risk in its organisation is and will remain as low as reasonably practicable.
The Australian Transport Safety Bureau recommends that Sea World Helicopters Pty Ltd develops appropriate policy and actionable objectives within its safety management system to bring the focus of the safety management system to the management of aviation safety risk.
The Safety Management System – Volume 5 has been updated to separate the definition of risk references to ‘Flying Risks’ and ‘Ground/Operational Risks’, to ensure both types of risks are addressed in a balanced and regular manner The SWH Safety Policy has also been amended to include the definition ‘Flying Risks’ and ‘Ground/Operational Risks’ and to ensure that these risks are addressed in a balanced and regular manner.
Sea World Helicopters provided an updated safety policy. The operator now delineates between ‘flying risks and ground/operational risks’ to ensure employees understand the difference. However, elements of the existing policy require Sea World Helicopters to “Establish and measure our safety performance against realistic objectives and/or targets” and the ATSB recommended that the operator “develops appropriate policy and actionable objectives”. The operator’s objectives were dated 1 June 2023 and were not changed following the recommendation to create actionable objectives. Objectives published remain generic and non-specific and achievable through non-specific and ineffective activity.
Sea World Helicopters Pty Ltd (SWH) has reviewed and provides the below summary of changes in direct response to A0-2023-001-SR-38.
SWH has utilised, what it has always believed to be, effective Safety Policy and actionable objectives within the Safety Management System. This contains the Safety Management Policy, Framework and Objectives for which the Safety Management System is managed throughout the organisation. 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 to the exposition.
What has been done:
A copy of the updated SMS section relating to the above is attached for your reference.
Sea World Helicopters continues to manage all matters through their safety management system. However, they have stipulated a difference between ‘flying risks and ground / operational risks’. While the operator’s objectives have not been designed for their specific operation, in line with CASA guidance on SMS the operator has created a ‘SMART’ structure around the existing objectives that provides tasks and expectations for the safety manager to direct their efforts in development and management of safety at Sea World Helicopters.
Flight operations hazards are now subject to an objective to increase the rate of reporting. Sea World Helicopters now requires pilots to report at least one hazard associated with aviation safety risk per annum. While this may result in a low number of reports it is an important step in setting the expectations of the organisation. The operator provided evidence that reports relating to aviation safety risk had increased to 25% of the total. This represents an increase in the number of issues being managed for resolution.
The operator has undertaken to monitor reporting on a quarterly basis which will give it an indication of the health of the reporting system and a wider picture of changing risk and management of safety within the organisation.
Sea World Helicopters has also developed an objective to address hazards raised within 12 hours of reporting and to rectify hazards within 48 hours. Through this the operator seeks to avoid escalation of risk. Additionally, feedback and responding to hazards is an important part of encouraging reporting.
The operator has identified through SMS processes that conflict points in its scenic flight operation carry high risk. It considers their current exposure to risk to be as low as reasonably practicable and tolerable with oversight by senior management.
However, there are foreseeable risks in the scenic flight operation. The degradation of control measures or increase in frequency of flights could cause an increase in risk which may cross their thresholds for tolerance. Being aware of that requires constant work.
The ongoing development of Sea World Helicopters' SMS with respect to monitoring their environment and minimisation of aviation safety risk will be vital to ensuring the organisation can identify increasing risk and take steps to mitigate it. Such measures may include controls the organisation currently considers too costly to implement.
