Sea World Helicopters' change management process, conducted prior to reopening the park pad, did not encompass the impact of the change on the operator's existing scenic flight operations. Crucially, the flight paths and the conflict point they created were not formally examined, therefore limitations of the operator’s controls for that location were not identified.
Sea World Helicopters has made changes to the tools used to implement change in their organisation. Its 'change request form' now carries a series of pertinent questions that must be considered prior to initiation of a change including asking the initiator to consider the impact on wider areas and aspects of the business and whether the change impacts any existing controls. Its 'change management planner' requires a description of scope of the change and areas impacted and follow up and post implementation assessment for all changes.
These new supports to the change management process provide employees the tools and reach they need to protect risk controls and identify hazards and opportunities that arise during change.
Initial response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
Change Management processes, as documented in our response to the report, were conducted and considered all conflict points within flight paths.
As a result of that Change Management process, and assessing the risk, all pilots received a specific training sign-off to operate out of the overwater Park Pad, which as detailed in your report included specific consideration of See and Avoid techniques in relation to the known conflict point.
ATSB comment
The report discusses the change management conducted for the reintroduction of the park pad and the issues in that activity in detail. The process conducted was limited in scope and used a job hazard analysis to assess the park pad in isolation. The operator contends that the decision‑maker’s review was equivalent to formal change process as controls of see-and-avoid and check flights at the park pad were introduced.
The report relates that while the operator was aware of the existence of the conflict point, it did not consider the introduction of the conflict point to present an unusual risk. That decision‑maker’s review, as related by the operator, was focused on park pad operations, included assumptions and was conducted without the benefit of a wider risk assessment.
There was no mention of heliport traffic which was also affected by the introduction of a conflict point. The ATSB investigation found that the conflict point between flight paths contained several aspects of risk (as described in a separate finding and safety issue). While the ATSB notes that pilots inbound for the heliport were also advised to look and call if necessary, there was no documented guidance or procedure changes for flights inbound for the heliport which were now affected by the change.
Had the operator expanded the scope of the change management process, conducted formal risk assessment and reviewed previously implemented risk controls, it is likely that the operator would have had a greater understanding of the risks associated with the flight path and conflict point. That in turn would have increased the likelihood of identification of accessible supports to see‑and-avoid and reduced risk.
The ATSB believes the operator’s safety assurance processes will benefit from considering the widest possible reach of introduced change using best practice methods of formally identifying hazards and assessing and controlling risks.
The Australian Transport Safety Bureau recommends that Sea World Helicopters Pty Ltd improves change management processes by ensuring assessments are expanded beyond the area of change to the wider organisation. Additionally, the operator should test assumptions and perform risk analysis to support risk‑focused decision‑making, to ensure new opportunities to control risk are identified and existing risk controls are maintained.
Post-accident SWH conducted a thorough and detailed assessment of all procedures and the entire Exposition.
These new procedures and Exposition amendments were assessed and approved by CASA from the highest levels to be fully compliant with the CASR regulations prior to the recommencement of operations. This also included the change management procedures of the exposition.
SWH believe that these changes and new operational procedures eliminate the chance of an incident of this type ever occurring again. SWH continue to disagree with the ATSB’s opinion regarding the use of the EC130 and also the ATSB opinion that the visibility from this aircraft had any direct impact on this accident.
There is no new information in the response relevant to the recommendation.
Sea World Helicopters stated that it conducted a thorough review of all procedures and was complaint with CASRs. That is not relevant to this recommendation.
Sea World Helicopters also stated that it disagrees with the ATSB’s opinion regarding the use of the EC130 and also the ATSB opinion that the visibility from this aircraft had any direct impact on this accident. The ATSB did not offer an opinion on the suitability of EC130 helicopters, and this is also unrelated to the recommendation.
Sea World Helicopters provided change documents. Some, including the document provided for this recommendation, stated risk assessment required ‘Y’ and no risk assessments were provided.
Please provide evidence of:
SWH has utilised, what it has always believed to be, an effective change management procedure with the documented Management of Change process contained within the SWH Exposition. This contains the process for which change and improvements, are identified and 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. Through the reassessment of this Safety Finding and the subsequent amendments to our change management framework, SWH has changed its approach to evaluating and implementing organisational changes. The updated Change Management Planner, the updated Change and Improvement Form and the introduction of structured assessment and review mechanisms ensure that all changes are considered in the context of the wider organisation, that risk-focused decision-making is embedded throughout the process and that existing risk controls are maintained or enhanced.
What has been done:
Sea World Helicopters has improved its change management processes and developed risk management plans for its activities. An example of implementation of the change management system showed that Sea World Helicopters considered hazards associated with an activity, consulted across the organisation to identify hazards and safer ways of performing the task, and mitigated risk following conduct of a risk analysis.
