Safety Issue

Reopening the Park Pad in March 2022 created an increased risk of collision with traffic operating from the existing heliport. The conflict point was placed at a location where:

• there was a higher workload for both pilots
• both pilots needed to consider the effect of helicopter downwash on surface traffic
• it was less likely that an inbound pilot would notice a change in the status of a helicopter on the ground
• it was more difficult for an outbound pilot to acquire traffic
• helicopters would close on each other vertically and laterally, decreasing likelihood of detection
• the operator's airborne collision avoidance systems would not provide traffic advisories.

Response by Sea World Helicopters

Sea World Helicopters made the following statement:

Reopening the park (overwater) pad reintroduced a known risk that was there in 2019 and for decades prior and had been operating for 9-months prior to the accident. 

The operator stated that all associated risk with the change was managed by a group including:

…the only two pilots employed on a fulltime basis at that time plus the CEO [who was] a pilot and an examiner of airmen with 40+ years of flying experience around Australia including as Check Pilot at SWH under previous management. 

The operator also proposed justifications for the limitations of the conflict point in the dot points below from the perspective of day-to-day operation at the helipad, rather than exploring alternatives from a design perspective. The operator assessment included:

• Pilot workload was no different to any other take-off or landing.
• Surface vessels had been a consideration for the last 40+ years and a minor consideration.
• Pilots would notice changes to status of other helicopters through proper communication procedures and visual scanning techniques ensuring situational awareness.
• The pilot of XKQ must not have looked right or he would have acquired the inbound traffic.
• Closure angles are not a concern, and pilots will see the other helicopter with standard scanning techniques.
• TCAS is not suited for low level environments.

The operator also obtained statements from experienced pilots who have flown both the EC130 and AS350 aircraft which state that with normal scanning techniques, both pilots involved in the accident flights would have had visibility of each other for the entire time. The operator also provided a video filmed from inside an EC130 at the park pad showing coordination with another company helicopter on approach to the heliport and keeping that helicopter in sight. 

ATSB comment

The ATSB does not agree that because a conflict point existed in prior occasional operations that it should be accepted as-is and without formal analysis in newly developed operations by a different company. More so when the previous company was using additional controls to support pilots in managing separation. Safety analysis in the report explains these differences. 

This safety issue highlights issues in the design of the conflict point. Not all intersections carry the same risks. A same level conflict point at 500 ft in cruise flight for example mitigates pilot workload and surface traffic concerns as well as improving traffic acquisition and making TCAS available. 

In seeking to justify the existence of the conflict point in its current form, Sea World Helicopters assumes that traffic will always be visible, and pilots will never miss seeing other traffic if they just look, and the operator misses the point that all the dot points listed contribute to diminishing the ability of pilots to succeed in identifying and avoiding conflicting traffic that the design of the operation has committed them to.