[Peetwo]

Gold Coast Chopper collision.

Two 'links' below; avoid the Popinjay media bluster  – really.

Link 1.

Link 2. ATSB

Addendum: Popinjay to the rescue - Season 3

ATSB calls for research and testing for fitment of constant wear lifejackets with multipoint seatbelts



The ATSB is calling for research into the correct fitment of lifejackets while wearing aircraft multipoint seatbelts after finding that the passengers on board both helicopters involved in the 2 January 2023 midair collision at the Gold Coast were incorrectly restrained.

“The ATSB was unable to establish the level of contribution the incorrect fitment of restraints contributed to individual passenger injuries in this tragic accident,” ATSB Chief Commission Angus Mitchell said.

“However, in the event of an accident we do know that the correct fitment of seatbelts improves occupant survivability outcomes.”

Mr Mitchell said the ATSB investigation highlighted that the wearing of lifejackets potentially interfered with the correct fitment of the helicopters’ multipoint seatbelts.

“Occupants in helicopter tourism operations worldwide are at risk of increased injury in an accident due to inadvertent incorrect use of seatbelts,” he said.

“There is no readily available guidance, either from lifejacket manufacturers or regulatory authorities, regarding the correct fitment and use of constant wear lifejackets when occupants are using multipoint seatbelts.” 

For scenic flight helicopter operations over water, such as in the midair accident flight, regulators require that passengers wear a lifejacket in addition to their seatbelt. This is to ensure that passengers can access their lifejacket in a timely manner in the event of an emergency ditching or collision with water. 

“However, an occupant must survive the impact before the use of the lifejacket will be required and therefore correct fitment of their seatbelt is vital to ensure the restraints and energy attenuating features of seats work as designed.”

Most operators provide their passengers with pouch‑style constant wear lifejackets. While the lifejacket and multipoint seatbelts are commonly used together, there is no available guidance about how to integrate them while maintaining their functionality.

Manufacturer instructions for the fitment of all pouch-style constant wear lifejackets requires them to be worn around the waist and positioned at the middle of the body. However, doing so interferes with the correct fitment of a multipoint seatbelt. 

“The correct fitment of any seatbelt requires the lap portion to be worn low and tight across the hips,” Mr Mitchell stressed. 

“In this accident the operator’s ground and flight crew were not aware of how to integrate the constant wear lifejacket with seatbelts without affecting correct fitment of the seatbelt. 

“This led to the inadvertent incorrect fitment of passenger seatbelts.”

Mr Mitchell said the ATSB has issued a safety advisory notice calling for research and testing to develop guidance on integration of constant wear lifejackets with multipoint restraints so that operators and passengers can use these two pieces of equipment together without increased risk of harm. 

“The outcomes of this research and testing would contribute to a solution for the widespread problem of inconsistent and frequently incorrect wearing of seatbelts,” he said. 

“Development of guidance and procedures for aircraft operators to correctly integrate constant wear lifejackets with a multipoint seatbelt will benefit passengers across helicopter tourism operations worldwide.”

Read the safety advisory notice: Fitment of constant wear lifejackets with multipoint seatbelts

Publication Date
09/04/2025

Link: Safety issues and actions

Hmm...

Focus of the SMS

Safety issue description

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.

Issue number: AO-2023-001-SI-07
Issue owner: Sea World Helicopters Pty Ltd
Transport function: Aviation: General aviation
Current issue status: Open – Safety action pending
Issue status justification: To be advised

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.


Safety recommendation to Sea World Helicopters Pty Ltd

The ATSB makes a formal safety recommendation, either during or at the end of an investigation, based on the level of risk associated with a safety issue and the extent of corrective action already undertaken. Rather than being prescriptive about the form of corrective action to be taken, the recommendation focuses on the safety issue of concern. It is a matter for the responsible organisation to assess the costs and benefits of any particular method of addressing a safety issue.

Recommendation number: AO-2023-001-SR-38
Responsible organisation: Sea World Helicopters Pty Ltd
Recommendation status: Released

The Australian Transport Safety Bureau recommends that Sea World Helicopters Pty Ltd develops appropriate policy and actionable objectives within its safety management system to bring the focus of the safety management system to the management of aviation safety risk.

Hmm...I can understand the pushback from the company in terms of total liability cost, reputation etc..etc. The Coroner's inquest will be interesting??

MTF...P2