Sea World Helicopters' change management process, conducted prior to reopening the park pad, did not encompass the impact of the change on the operator's existing scenic flight operations. Crucially, the flight paths and the conflict point they created were not formally examined, therefore limitations of the operator’s controls for that location were not identified.
Response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
Change Management processes, as documented in our response to the report, were conducted and considered all conflict points within flight paths.
As a result of that Change Management process, and assessing the risk, all pilots received a specific training sign-off to operate out of the overwater Park Pad, which as detailed in your report included specific consideration of See and Avoid techniques in relation to the known conflict point.
ATSB comment
The report discusses the change management conducted for the reintroduction of the park pad and the issues in that activity in detail. The process conducted was limited in scope and used a job hazard analysis to assess the park pad in isolation. The operator contends that the decision‑maker’s review was equivalent to formal change process as controls of see-and-avoid and check flights at the park pad were introduced.
The report relates that while the operator was aware of the existence of the conflict point, it did not consider the introduction of the conflict point to present an unusual risk. That decision‑maker’s review, as related by the operator, was focused on park pad operations, included assumptions and was conducted without the benefit of a wider risk assessment.
There was no mention of heliport traffic which was also affected by the introduction of a conflict point. The ATSB investigation found that the conflict point between flight paths contained several aspects of risk (as described in a separate finding and safety issue). While the ATSB notes that pilots inbound for the heliport were also advised to look and call if necessary, there was no documented guidance or procedure changes for flights inbound for the heliport which were now affected by the change.
Had the operator expanded the scope of the change management process, conducted formal risk assessment and reviewed previously implemented risk controls, it is likely that the operator would have had a greater understanding of the risks associated with the flight path and conflict point. That in turn would have increased the likelihood of identification of accessible supports to see‑and-avoid and reduced risk.
The ATSB believes the operator’s safety assurance processes will benefit from considering the widest possible reach of introduced change using best practice methods of formally identifying hazards and assessing and controlling risks.
To be advised
The Australian Transport Safety Bureau recommends that Sea World Helicopters Pty Ltd improves change management processes by ensuring assessments are expanded beyond the area of change to the wider organisation. Additionally, the operator should test assumptions and perform risk analysis to support risk‑focused decision‑making, to ensure new opportunities to control risk are identified and existing risk controls are maintained.
