Reliance on alerted see-and-avoid
Date issue released
Issue number
Issue Status
Closed – Adequately addressed
Transport Function
Aviation: General aviation
Issue Owner
Sea World Helicopters Pty Ltd
Mode of Transport
Aviation
Safety Issue Description

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.

As described in our response, TCAS and EFB were available to both pilots, but as stated within your own investigation would not have provided any assistance to either Pilot in the incident.

The See and Avoid principle if used correctly would have made both pilots aware of their position at all times, which they failed to utilise.

SWH as stated previously have introduced additional procedures for the management of aircraft in and around the Sea World Heliport.

ATSB comment

The report states that EFBs would have supported pilots. The stated availability of controls does not represent implementation of those controls. 

The operator assumes that deviations from expected outcomes in see-and-avoid can only be due to pilots not looking and not to limitations in the system itself. This approach ignores copious research detailing the limitations of visual and information processing in pilots, the influence of operational requirements, environmental conditions, technology and aircraft characteristics.

However, in contrast to the Sea World Helicopters response to the safety issue, proactive safety action has been taken by Sea World helicopters that will support pilots’ implementation of see‑and-avoid.

Issue Status Justification

The safety action taken by the operator implements additional controls to enhance see-and-avoid and will support pilot's implementation of see-and-avoid.

Proactive action
Action number
AO-2023-001-PSA-304
Organisation
Sea World Helicopters Pty Ltd
Action date
Action Status
Closed
Action description

Sea World Helicopters introduced the following risk controls into their operation to reduce pilots’ reliance on unalerted see-and-avoid:

  • A Pad Boss Traffic Advisory role, a trained on-the-ground staff member, to supervise movement on the helipad and communicate with pilots before they depart to advise departure is allowed at the pilot’s discretion.
  • Air Traffic Systems (Stratus 3 Open ADS-B Mode) map display installed in company helicopters to show the pilot the location of other aircraft in the vicinity.
  • Increased communications protocols for SWH pilots including mandatory 'Final' call acknowledgement by stationary SWH aircraft pilot.
  • Additional Aircraft Visibility including:
    • high intensity strobe lighting added to all SWH aircraft
    • Airbus Strobe Painting System added to main rotor blades.
  • Mandatory human factors awareness training for all staff (previously delivered to pilots only).