Sea World Helicopters commenced operations with EC130 helicopters without a formal change management process. Implementation of the operator's documented procedures would have increased the likelihood of formal consideration of various risk controls, including controls that were previously applied for the introduction of aircraft.
Sea World Helicopters has improved its change management process, and the tools used to enact it. It has listed the helicopters its pilots are permitted to operate by registration mark. To gain approval, any new aircraft must be assessed against a checklist. The checklist covers aircraft fitment and ensures that equipment, including that used to mitigate the risk of midair collision, is present. Any elements that are not present must undergo formal risk assessment. The checklist requires the HOFO and CEO to approve aircraft and ensures that they do so with full knowledge of the existence or otherwise of those controls.
Initial response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
…the EC130 type had been utilised by the operation since 2016 and was listed in the company’s operations manual and the AOC as an approved aircraft.
The pilots were approved to fly the aircraft type.
There was no change to the operation.
Both Pilots involved in the accident were experienced on the EC130 type.
Subsequently there was no Change Management requirement.
ATSB comment
As discussed in the report, the operator’s change management procedure carried some ambiguity with respect to the requirement of change processes for additional helicopters. The operator’s interpretation was that it was not necessary and did not conduct change management for the introduction of new helicopters. However, replacing the AS350 helicopters used in scenic flights with EC130s did not provide for direct continuity in scenic flight operations or provision of risk controls and required changes in procedures and training.
The assessment of whether the additional helicopters maintained or improved safety relied on assumptions rather than formal risk analysis. Issues which could have been identified through a formal change and risk management process persisted during the implementation of the helicopters and undermined previously documented risk controls.
The operator’s remaining EC130 aircraft is still being operated without formal risk assessment of the differences from the other helicopters in its fleet. However, the ATSB notes that following the midair collision various safety improvements have been made to bring that helicopter to the standard the operator now requires. Those improvements could have been otherwise achieved through a formal change management process.
The operator’s position that no change management is required for introduction of additional helicopters means that its newly implemented risk controls for prevention of midair collision remain at risk of failure when new helicopters are introduced in the future.
The Australian Transport Safety Bureau recommends that Sea World Helicopters Pty Ltd clarifies its change management procedure so that the introduction of additional helicopters and other potentially disruptive changes are captured by change and risk management processes to ensure aviation safety is maintained or improved.
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:
To specifically address the ATSB’s point of managing ‘the introduction of additional helicopters’ the following has been implemented:
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.
