Sea World Helicopters commenced operations with EC130 helicopters without a formal change management process. Implementation of the operator's documented procedures would have increased the likelihood of formal consideration of various risk controls, including controls that were previously applied for the introduction of aircraft.
Response by Sea World Helicopters
The operator disagreed with this safety issue. It stated:
…the EC130 type had been utilised by the operation since 2016 and was listed in the company’s operations manual and the AOC as an approved aircraft.
The pilots were approved to fly the aircraft type.
There was no change to the operation.
Both Pilots involved in the accident were experienced on the EC130 type.
Subsequently there was no Change Management requirement.
ATSB comment
As discussed in the report, the operator’s change management procedure carried some ambiguity with respect to the requirement of change processes for additional helicopters. The operator’s interpretation was that it was not necessary and did not conduct change management for the introduction of new helicopters. However, replacing the AS350 helicopters used in scenic flights with EC130s did not provide for direct continuity in scenic flight operations or provision of risk controls and required changes in procedures and training.
The assessment of whether the additional helicopters maintained or improved safety relied on assumptions rather than formal risk analysis. Issues which could have been identified through a formal change and risk management process persisted during the implementation of the helicopters and undermined previously documented risk controls.
The operator’s remaining EC130 aircraft is still being operated without formal risk assessment of the differences from the other helicopters in its fleet. However, the ATSB notes that following the midair collision various safety improvements have been made to bring that helicopter to the standard the operator now requires. Those improvements could have been otherwise achieved through a formal change management process.
The operator’s position that no change management is required for introduction of additional helicopters means that its newly implemented risk controls for prevention of midair collision remain at risk of failure when new helicopters are introduced in the future.
To be advised
The Australian Transport Safety Bureau recommends that Sea World Helicopters Pty Ltd clarifies its change management procedure so that the introduction of additional helicopters and other potentially disruptive changes are captured by change and risk management processes to ensure aviation safety is maintained or improved.
