The Civil Aviation Safety Authority's Part 133 (air transport - rotorcraft) exposition requirements did not adequately address the risk to passenger safety from a visual flight rules inadvertent instrument meteorological conditions event.
CASA response
On 21 November 2023, the Civil Aviation Safety Authority advised the ATSB that:
This safety issue is misconceived as it does not consider the safety management potential of the combined air transport regulatory suite. It also relies, as does the report, entirely on the context of needing to add either additional equipment (instrumentation), additional systems (SAS, autopilots) and additional flight crew training (instrument flight training) and flight crew recency (IF recency), as the solution to IIMC events. Whilst these may offer some assistance, they are in most instances reactive, after IIMC has occurred, and are expensive fixes, which notably, the industry has already rejected.
CASA recommends the safety issue is withdrawn for the reasons outlined in this overall feedback and substituted with an action to include further guidance material on IIMC within the AMC/GM for Part 133 of CASR. As is the case with EASA and transport Canada, noting transport Canada’s material is primarily associated with “white out condition IIMC” which is a very rare event in Australia. CASA also notes the numerous articles it has already published on VFR into IMC in its Flight Safety magazine on this issue.
ATSB comment
Throughout the course of this investigation the ATSB repeatedly found optional VFR into IMC risk controls available to the operator that were not mandated for their day VFR pilots. This was explained in the safety analysis and has extended to the operator’s responses to the safety issues, citing the provision of training outside the regulatory requirements as impractical and uncommercial. Performance-based approaches to safety should complement prescriptive approaches and not replace them as it can lead to the treatment of safety requirements as ‘optional’ and may result in competitive advantages to operators with lower safety standards. Performance-based approaches should also be responsive to outcomes, such as accidents, so that safety requirements can be adjusted to meet the acceptable level of safety.
While equipment, systems and training will greatly improve the chances of recovering from a VFR into IMC event, this is not the extent of the ATSB’s report, which has also discussed operational information, organisational information, research studies of VFR into IMC and intervention strategies, including avoidance and recovery. The report also acknowledges the cost of the autopilot system for the EC130 helicopter and the helicopter industry's opposition to basic instrument flying training, which was a majority but not a consensus.
The ATSB acknowledges the work done by CASA to develop and deliver flight planning and weather assessment educational material, safety seminars and guidance material, which included the "Don’t push it, land it | Flight Safety Australia" campaign for helicopter pilots to make the decision to land when confronted with deteriorating weather. However, the “Don’t push it, land it” strategy is only applicable to helicopters operating underneath the cloud base and is not applicable to VFR over the top. In this accident, the pilots proceeded VFR over the top before the VFR into IMC event.
The Australian National Aviation Safety Plan 2021-2023, to which the ATSB and CASA were contributing agencies, stated Australia’s acceptable level of safety performance is:
"No accidents involving commercial air transport that result in serious injuries or fatalities, no serious injuries or fatalities to third parties as a result of aviation activities and improving safety performance across all sectors."
Therefore, any risk assessment of a fatal commercial air transport accident by CASA should be consistent with Australia’s acceptable level of safety performance. To progress towards this level of safety, CASA need to capture lessons learned from fatal accidents in Australia in the Australian aviation standards.
In addition to this accident, the ATSB has recently investigated a fatal VFR into IMC accident in Tasmania, AO-2018-078, by a commercial aeroplane pilot en route to collect passengers, a fatal VFR into IMC Part 135 (Australian Air Transport Operations—smaller aeroplanes) accident in Queensland, AO-2022-041, and are currently investigating a fatal Part 135 accident involving adverse weather in the Northern Territory, AO-2022-067. As CASA has not committed to taking safety action in response to this safety issue, the ATSB is issuing a safety recommendation.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority takes safety action to further address the risk to rotorcraft air transport (Part 133) passenger safety from a visual flight rules inadvertent instrument meteorological conditions event.
UPDATE 24 April 2024: The ATSB has granted a short extension for the recipient to provide further information regarding its response to this safety recommendation.
CASA emphasises the importance of avoiding instrument meteorological conditions as the primary risk mitigator for IIMC accidents.
To address the Safety Recommendation, CASA is taking several measures.
In collaboration with State Safety Program Interagency Aviation Safety Promotion Working Group, the Australian Helicopter Industry Association (AHIA) and other stakeholders, CASA is implementing a pilot safety campaign. The “Your safety is in your hands” campaign is specifically aimed at improving awareness and decision- making among pilots, including those operating in the rotary wing sector.
CASA will continue to develop tailored resources for the rotary wing sector, including education and safety promotion on practical measures for pilots to avoid IIMC events, including appropriate flight planning and the use of modern GPS navigation systems in day VFR operations.
CASA will continue to reinforce the message that we support and encourage rotary wing pilots to make a precautionary landing anywhere when it is safe to do so. In keeping with our policy and practice, CASA will also emphasise that we will not take enforcement action against a rotary wing pilot if they make a precautionary landing, provided it is performed for good reason and as safely as possible in the circumstances.
Overall, CASA's approach involves a comprehensive strategy of education, engagement, and tailored resources to address the Safety Recommendation and enhance safety awareness and decision-making among rotary wing pilots.
CASA considers that providing operators comprehensively implement the existing regulatory requirements (such as requirements for weather assessment procedures, diversion and weather avoidance procedures and aerodrome information procedures), sufficient safety defences are in place to reasonably mitigate relevant safety risk.
However, CASA acknowledges that operators may not have comprehensively implemented these requirements in the manner envisaged by CASA. Additionally, even in a mature operator, individual pilot decision making is likely the final opportunity to avoid an IIMC incident. That decision making should be guided, encouraged and supported by clear and robust operator processes and procedures.
CASA notes that deferred provisions of the Flight Operations Regulations which will come into force by the end of 2026 are designed to enhance the organisational safety performance of Australian air transport operators and assist in the prevention of accidents of this nature. The key organisational safety requirements due to come into force for CASR Part 133 operators include training and checking, safety management systems and human factors/non-technical skills training.
To ensure that individual pilot decision making is fully supported, potentially in the face of operator-based pressure to ‘just go and have a look’, CASA proposes to amend multiple documents, both externally and internally focused, to incorporate specific acceptable means of compliance exposition content regarding inadvertent instrument meteorological avoidance procedures together with a risk assessment and task rejection process. CASA’s internal principle and protocol documents will also be amended to incorporate this content to ensure that these procedures can be appropriately checked during surveillance events. National Operations and Standards Division will discuss with Surveillance Branch an appropriate timeframe to conduct targeted surveillance in relation to these operator processes and procedures.
CASA proposes to amend the following documents to specifically incorporate IIMC avoidance procedures together with the use of a Flight Risk Assessment Tool (FRAT):
Any sample manual content published by CASA constitutes an acceptable means of compliance (AMC) and allows an operator to satisfy CASA that they comply with a regulatory requirement if they choose to use and follow the AMC material; however, they may also propose alternative means of compliance to the AMC if they so desire. This alternative means will need to be assessed and found acceptable for the purpose by CASA.
In this regard CASA will amend the following documents so that CASA inspectors look for the right content, and assess that content against the right standards during initial AOC applications and subsequent surveillance events:
CASA will also consider amending the following 2 documents to identify alternative means of highlighting the HF/NTS and safety threat IIMC information in addition to or instead of, through these ACs.
It should also be noted that CASA has recently published a sample training and checking manual, Part 133, 135 or 138 sample training and checking manual, that incorporates, IIMC avoidance and reduced visibility encounters as a discussion point, to be checked during each operator proficiency check noting that all Part 133 operators will be required to implement formal training and checking systems by early 2026. Training and checking systems for flight operators | Civil Aviation Safety Authority (casa.gov.au)
The ATSB acknowledges CASA's proposed strategy of education, engagement, and resources to rotary wing pilots and a focus on avoidance strategies to reduce the risk of VFR into IMC rather than recovery mitigations. As noted in the CASA response, pilots can have operator-based pressure to ‘just go and have a look’.
The practice of 'having a look' when conditions were forecast to be marginal has been a recurring theme of accident investigations. In some cases, the practice of 'having a look' has been condoned by operators, which can lead to pilots increasing their appetite for weather related-risk without the training or procedures to recover from an inadvertent IMC event. Any steps to reduce this practise is a positive move.
While CASA considers the existing regulatory requirements provide sufficient safety defences, the ATSB’s analysis indicated that helicopter VFR into IMC occurrences result in a higher proportion of accidents than aeroplane VFR into IMC occurrences. However, the ATSB acknowledges that there have been fewer helicopter VFR into IMC occurrences than aeroplane VFR into IMC occurrences.
The ATSB has made the assessment that CASA's response to address the risk of VFR into IMC through the CASR Part 133 exposition requirements for operators to address inadvertent instrument meteorological avoidance procedures together with a risk assessment and task rejection process, supported by additional exposition content direction to the CASA’s Surveillance Branch, will assist in reducing the risk to passenger safety from VFR into IMC. The ATSB will continue to monitor the introduction of these measures and their effectiveness.
