Safety Issue

Sea World Helicopters' implementation of their SMS did not effectively manage aviation safety risk in the context of the operator's primary business. Additionally, their objectives were non-specific, and the focus of safety management was primarily ground handling and WHS issues. This limited the operator's ability to ensure that aviation safety risk was as low as reasonably practicable.

Response by Sea World Helicopters

The operator disagreed with this safety issue. It stated:

Prior to Dec 2018, the PHS [professional helicopter services] management team gave a presentation to the then current staff of SWH where we stressed the importance… of Safety. It was part of our Vision and our Ethos, and we were bringing that to SWH.

It detailed our Vision to be recognized as Australia’s safest and most enjoyable helicopter tourism company and our Ethos – Safety is the foundation of what we do. Experience and enjoyment are the outcomes. These were our objectives, they are clear, concise and were published.

From the outset changes were made, in consultation with both the Chief Pilot and Safety Manager, this included changing flight paths and the building of the facility to improve safety, not only on the ground but for the movement of aircraft in all phases of flight.

Improving safety was the primary reason for making these changes.

Sea World Helicopters also stated that the ATSB had:

…continuously ignored the effects of COVID-19 and its effects throughout the world and the health issues that had to be dealt with in the SWH business. Comparing flight incident report numbers from year to year but ignoring the numbers of flights as a contributing factor. Total flights in 2019 were 20,054 and the total flights for 2020/2021 were 7195 (an average of 9 per day). In 2020 and 2021 the company operated mostly with just one pilot, that pilot was the HOFO/HAAMC.

Passenger numbers and staffing numbers decreased along with risks to report. At one point the office closed for three months. When flights did occur the passenger demographic was totally different to pre-COVID. The passengers prior to Jan 2020 were 80% Chinese Mainland groups, nearly all of whom, did not speak English. These tourist groups are yet to return to Australia.

And:

…we find the last 7 months prior to the accident, the safety management in this period is ignored as a subject by the ATSB. The amount of incident reports increased, there were more safety meetings and briefings about safety meetings in a period of time than we can find recorded for the period before Dec 2018.

In response to this finding the operator also states:

When at work the SWH team were encouraged to work as only a small team can, there was a safety suggestion box put in the team’s breakout room for them to provide any type of safety feedback, including anonymously. Minor items were done on the spot where possible. Items relating to flight safety whilst sought did not arrive as for these two years there was between one and two pilots only. 

In addition to the Safety Manager, we employed a Quality, Safety & Compliance Officer, who although part-time, attended all weekly management meetings. Assistance was still provided by the PHS Safety Manager in matters of compliance and documentation.

SWH thoroughly believes it manages risk and the safety of its staff and customers very well. 

ATSB comment

The operator’s response to the finding does not address effective engagement with aviation safety risk. The aspirational vision of the company did not translate into defined objectives of the safety management system. As discussed in the report in Safety policy and objectives, the objectives of an SMS are intended to be practical achievable goals. 

The effect of COVID-19 was discussed in the report in the Disruption due to global pandemicsection. Following draft review, the operator provided flight numbers which have been used to normalise reporting by flight hours to account for the lower activity during COVID-19. Flight operation reports were shown to reduce after the change of ownership while WHS reporting did not, and did not recover after the pandemic.

The 7 months of SMS prior to the accident were covered in detail in various places within the Safety management section. The report related the success of the operator’s SMS in that period in managing ground handling and WHS matters. While WHS is a very important and legislated element, as stated in CASA guidelines, an aircraft operator’s SMS should concentrate on aviation safety risk. 

The operator’s primary business was high frequency low duration helicopter flights from 2 nearby helipad facilities. The report agrees that the changes made were intended to improve safety, but as the SMS was not focused on aviation safety risk, processes which could have contained unintended consequences of those changes were not used.

The operator has not so far provided evidence of defining safety objectives and support for ongoing engagement with aviation safety risk, and is therefore still at risk of being limited in its ability to ensure that risk in its organisation is and will remain as low as reasonably practicable.