Esso Australia did not have a procedure for a helicopter recovery from inadvertent IMC during hoist operations or recovery procedures for EGPWS alerts or advisories.
The Australian Maritime Safety Authority, with direct control of key national emergency response arrangements, did not have the required understanding of its central role in any response, regardless of location. Consequently, its support to, and coordination with, the control agency in relation to emergency towage, salvage and refuge was inadequate, inconsistent with National Plan principles of a single, integrated and comprehensive response and significantly prolonged 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.
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 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.
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.
United Salvage was severely limited in its ability to provide the required salvage services as it did not own, operate or directly control any towage vessels for which it relied on towage providers. This limitation was not made clearly known to Portland Bay’s master, owners or managers or involved authorities to allow them to properly assess whether the most suitable towage vessels, including the emergency towage vessel, had also been promptly deployed for salvage and emergency response.
Response by United Salvage
The Australian Maritime Safety Authority’s process to issue directions was inefficient and resulted in excessive time to issue directions allowing Portland Bay to enter Port Botany as a place of refuge. While this delay did not further prolong the emergency, such delays increase risk in time‑critical situations.
The decision height for assessing whether an aircraft met Wave Air’s stabilised approach criteria was too low.
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.
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.
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.
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.
Aircraft defects were not written on the maintenance release, leading to several defects not being rectified or managed.
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.
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.
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' 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.
Response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
