Implementation of helicopters without change management

Post accident Sea World Helicopters (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 Management have introduced improvements into the company’s Change Management processes to encourage the team members to:

1. Review previous assessments and assumptions.
2. Analyse data of those assessments to see if it supports or contradicts the previous assumptions, and
3. To continually brainstorm potential changes and their impacts, both positive and negative.
- SWH has the Agenda item of Change Management in each SWH Management and SWH Safety Meeting to ensure all ‘Changes’ within the business are being identified,
considered, managed, Risk Assessed and recorded.
- SWH continues to risk assess all identified changes prior to their introduction to the existing business.
- Triggers for Change include (but are not limited to):
   o Change of any helicopter type used by the business (owned or cross hired).
   o Introduction of any new or motorised equipment that may have capacity to create a hazard, harm or injury to personnel or the business.
   o All equipment Safety and User Manual documentation must be on hand and utilised prior to use.
   o Commencement of any new event or activity at SWH owned, operated or leased facility, in particular involving members of the public.

Sea World Helicopters stated that the process was “assessed and approved” by CASA to be compliant with civil aviation safety regulations. The recommendation is not related to the status of compliance and was made around a year after Sea World Helicopters recommenced operations. The recommendation is related to the fact that a change management process for the introduction of all new helicopters would reduce risk in the operation and help to protect risk controls the organisation relies on to prevent fatal accidents.

Sea World Helicopters provided what was stated to be an improved change management process dated 18 June 2025. It was a reformatted version of the process dated 28 June 2022, which was the same process that Sea World Helicopters provided to demonstrate that it did not need to conduct change management for new helicopters after the midair collision.

Sea World Helicopters (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 has re-assessed the specific Safety Finding. In doing so SWH has made the following amendments to the exposition. 

What has been done:

• The Change and Improvement form has been reviewed and amended to ensure a concise process is undertaken when any changes are made within SWH. This is achieved through:
  • Specific prompts, (Including Safety & Risk Controls and Operations & Procedures amongst other business areas), to initiate: Risk Assessments, Job Hazard Analysis, Change Management Plans, Action Tracker updates and reviews.
  • Inclusion of the Chief Executive Officer (CEO) signatory.
  • Inclusion of all Change and Improvements to management meetings. 

To specifically address the ATSB’s point of managing ‘the introduction of additional helicopters’ the following has been implemented:

• Amendment to the exposition that triggers the use of a checklist for any new aircraft being placed online at SWH.
• The creation of a GO/NO GO new aircraft checklist that mandates items, prompts for the completion of risk assessments along with pilot and crew training. Signatories to this form are the Chief Pilot and Chief Executive Officer.

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. 

Additionally, the operator has stipulated the specific helicopters that company pilots are authorised to operate by registration mark. To authorise a new helicopter for company use requires the use of a 'new aircraft checklist'. The new aircraft checklist identifies the risk controls required to meet the operator's standard and requires that the absence of any risk control is formally assessed and managed through rejection of the aircraft or mitigation of the increased risk.