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Ineffective operational risk assessment
Date issue released
Issue number
AO-2025-005-SI-01
Issue Status
Closed – Adequately addressed
Transport Function
Aviation: Air transport
Issue Owner
PHI International Australia Pty Ltd
Mode of Transport
Aviation
Issue finalisation date
Safety Issue Description

PHI International Australia’s operational risk assessment did not capture the risk of the crew’s limited experience on type at night.

Issue Status Justification

The ATSB considers the additional mitigating controls implemented by the operator are sufficient to address the risks of crew with low experience on the aircraft type at night, and that these improvements will likely prevent a similar occurrence.

Proactive action
Action number
AO-2025-005-PSA-01
Organisation
PHI International Australia Pty Ltd
Action date
Action Status
Closed
Action description

Following the occurrence PHI International Australia Pty Ltd implemented the following procedures:

  • All initial approaches during night flight to be conducted as an instrument approach, which ensures a more structured process with procedural barriers.
  • Night recency flights not to be conducted on a first flight back following any pilots leave.
  • Radar altimeter alert to be set at 500 ft.

PHI International Australia Pty Ltd also increased the risk loading on its operational risk assessment for pilots with less than 500 hours on type. Night flights with both pilots with less than 500 hours on type at night now require discussion with the senior base pilot regarding the additional risks relating to inexperience on type.