Portland Bay’s manager, Pacific Basin Shipping, did not provide the master advice about notifying authorities as per the ship’s safety management system emergency procedures, instead focusing on the engineering matters. This probably led to the master delaying the notification and the request for tug assistance.
The Australian Maritime Safety Authority’s Maritime Assistance Services procedures to support the National Plan for Maritime Environmental Emergencies (National Plan) were not effectively implemented. Consequently, there was a 12-hour delay in tasking the state’s nominated emergency towage vessel, Svitzer Glenrock, which significantly prolonged the emergency.
Transport for NSW (NSW Maritime), as the statutory agency responsible for ensuring that New South Wales was prepared to respond to an incident in accordance with the state’s plan that it maintained, had not effectively met this obligation. This resulted in the long delay in New South Wales assuming control of the incident and contributed to the inadequate coordination of the emergency response required for a single, integrated and comprehensive response and significantly prolonged the emergency.
Port Authority of New South Wales procedures to comply with its Port Safety Operating Licence and the NSW Coastal Waters Marine Pollution Plan were not effectively implemented. This resulted in delays to the required notifications and incident response, which contributed to prolonging the emergency.
The Port Authority of New South Wales did not have a proper and correct understanding of its responsibilities for emergency response under its operating licence and relevant state plans. This contributed to the inadequate coordination of emergency towage, salvage and refuge, which were critical for the single, integrated and comprehensive response required and significantly prolonged the emergency.
The Australian Maritime Safety Authority had not adequately managed the National Plan and annual exercises required to prepare for such incidents had not been conducted for 4 years before the incident. This probably resulted in the ineffective implementation of its Maritime Assistance Services procedures, the inefficient process for issuing directions and inadequate coordination of the incident with state authorities.
The training, supervision and checking flights conducted by Wave Air did not identify that an excessive approach speed was routinely being used by the pilot during the final approach to land.
The decision height for assessing whether an aircraft met Wave Air’s stabilised approach criteria was too low.
Wave Air's weight and balance system used an incorrect empty weight moment arm to calculate the aircraft's centre of gravity, and passengers were not weighed in accordance with their procedures.
During the 8-month period from November 2022 until the accident, Broome Aviation provided its pilots transitioning to operating the Cessna 310 with limited supervision, guidance and support, including management of the fuel system.
Broome Aviation pilots experienced pressure not to report aircraft defects on maintenance releases, and many pilots also experienced or observed pressure from individuals within the company management to conduct flights in aircraft with defects that they considered made the aircraft unsafe for flight.
Broome Aviation’s operations manual did not include a procedure for recording inflight fuel calculations. As a result, pilots adopted varying methods for fuel monitoring, leading to reduced assurance of accurate fuel management.
Aircraft defects were not written on the maintenance release, leading to several defects not being rectified or managed.
ARTC’s systems for management of track lateral stability did not lead to identification of the location as a special location potentially vulnerable to track instability.
Sea World Helicopters' procedure did not require ground crew to monitor the airspace up to the time of the helicopter departing the helipad. As the presence of hazards behind the helicopter could change significantly within a short space of time, helicopters routinely departed without current hazard information from ground crew.
At the time of park pad assessment, the Civil Aviation Safety Authority's guidance documents for establishment of helipads did not prompt assessment of flight path interaction with other already established traffic.
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.
Response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
Sea World Helicopters' standard inbound call from Porpoise Point was not a reliable alert for a pilot on the ground while boarding and interacting with passengers. Where collision risk on departure existed, a pilot on the ground would highly likely be focused on cabin preparation at the time of that inbound call.
Sea World Helicopters was reliant on CTAF calls, ground crew advice, and pilot visual detection of aircraft to ensure separation in VH-XH9 and VH-XKQ. Available additional controls for enhancing alerted see-and-avoid and reducing the risk of collision were not implemented.
Response by Sea World Helicopters
Sea World Helicopters provided the following response:
SWH state that additional controls for alerted See and Avoid were available.
Sea World Helicopters' passenger safety briefing system, comprising of a passenger safety briefing video supplemented by safety cards and ground crew advice had limited, inconsistent and incorrect information about correct fitment of seatbelts, location and emergency operation of the EC130 doors, and the emergency brace position.
