The Director of National Parks' risk management
Date issue released
Issue number
Issue Status
Closed – Adequately addressed
Transport Function
Aviation: General aviation
Issue Owner
Director of National Parks
Mode of Transport
Aviation
Safety Issue Description

The Director of National Parks did not actively manage the risk of the aerial culling task being conducted in the Kakadu National Park, or effectively supervise the operation. As a result, an increase in the number of crew, a change in helicopter type and change of helicopter operator all progressed without requisite risk management. This exposed crew to avoidable harm during low-level aerial shooting operations.

Issue Status Justification

The ATSB is satisfied that the risk of this safety issue has decreased through improvements to the Director of National Parks management of aviation safety risk, including the employment of an aviation specialist, the development of a suite of documents, and changes to its process for supervising operations.

Issue finalisation date: 24 February 2022

Proactive action
Action number
AO-2019-025-NSA-039
Organisation
Director of National Parks
Action date
Action Status
Closed
Action description

In January 2021, the Director of National Parks (DNP) advised of the following safety action:

The DNP has undertaken a range of actions to address safety issues relating to managing risks associated with aerial culling operations. In particular, the DNP has undertaken a specialist aviation safety review into its aerial culling operation risk assessment and aviation activity services contracts, resulting in:

  • the overarching and continuing suspension of aerial culling operations pending the outcome of all related reviews;
  • a new requirement for DNP-level approval of any future aerial culling operations; and
  • recruitment of specialist staff to KNP to deliver work health and safety (WHS) and training solutions and improvements with a focus on high-risk activities including aerial culling operations.

Helpfully informed by the ATSB’s review, next steps are underway and will include:

  • continued review of the DNP’s risk management policy (and the broad interactions with departmental and Commonwealth risk management frameworks) to address findings and recommendations in relation to the incident;
  • finalisation of a revised risk profile and risk assessment which addresses key risk areas prior to undertaking any future aerial culling operation;
  • completion of an updated suite of documentation and training specific to aerial culling operations extending to operating procedures, compliance, essential qualifications, planning and approvals; and
  • improvements to procurement and contract management processes for aviation activities including for aerial culling operations.

At a local KNP [Kakadu National Park] level, the DNP has also…

  • undertaken a KNP-focused risk workshop and planned supplementary staff workshops/training in risk planning and mitigation to enable staff and managers to confidently and effectively plan for aerial activities.

Organisation Response

Date Received
Organisation
Director of National Parks
Response Status
Closed
Response Text

On 23 February 2022, the Director of National Parks (DNP) provided a suite of documents including:

• Interim Aircraft Safety Policy
• Review of Interim Aircraft Safety Policy
• Aircraft Safety Policy
• Risk assessment for Kakadu Helicopter Operations
• Operational plan for the 2022 Kakadu culling program
• SOP for aerial culling
• SOP for safety around helicopters
• Flight harness use and maintenance procedure
• Daily aircraft SAR form.

The DNP also advised that it had employed an aviation safety professional to review policy and advise on amendments. This filled the gap between aviation service providers and auditing of those providers. Ensuring that DNP’s aims and intended usage were considered alongside development of safe operation.

The risk controls recorded set a standard of aircraft condition and operation. There is space to describe the evidence of compliance for each control, which when checked for implementation will provide for border understanding of risk for the crew, and the best opportunity for success of an aerial work mission. Verification of the completion of a risk assessment is required on the daily prestart checklist and requires the signature of the overall coordinator.

ATSB Response

The management of aviation safety risk is greatly improved through this suite of documents. There is also a requirement for supervision locked into the process.