[Peetwo]

Su_Spence breach of statutory duty and negligence timeline??

Via Search 4 IP:  Popinjay to the rescue on Croc Wrangler R44 fatal?

Have started reading through the 113 page marathon of a report and so far I have been simply gob smacked by the implications and inferences implied by what is a really poorly written Final Report - let's just say I can understand why Pip Spence and CO are very sensitive about this whole tragic & sordid occurrence...

Hint: The Final Report published safety issues IMO tell the real story behind this latest interagency top cover report:

CASA lack of effective process

Safety issue description

The Civil Aviation Safety Authority (CASA) did not have an effective process for assuring an authorisation would be unlikely to have an adverse effect on safety. As a result, CASA delegates did not use the available structured risk management process to identify and assess the risks, ensure appropriate and adequate mitigations were included as conditions of the approval, or assess the effects of changes on the overall risk.

Issue number: AO-2022-009-SI-01

Issue owner: Civil Aviation Safety Authority (CASA)

Transport function: Aviation: General aviation

Current issue status: Closed – Adequately addressed

Issue status justification:

If the revised process is conducted as documented, the safety issue should be addressed. - (Why no monitoring?)

Response by CASA

CASA did not accept the safety issue and contended that its process of risk assessment and decision-making in relation to the conduct of HEC operations in piston engine helicopters appropriately identified and mitigated the applicable risks as far as practicable. However, CASA acknowledged that its decision-making in relation to the issue of HEC approvals over time, and the applicable risk assessments could have been better documented. CASA also accepted that there was an absence of a structured and standardised approach to risk assessment and advised of the following proactive safety action.

Proactive safety action taken by CASA

Action number: AO-2022-009-PSA-191

Action organisation: The Civil Aviation Safety Authority

Action status: Closed

CASA implemented significant changes to its internal processes to ensure that the assessment and management of safety risks of new aviation activities (and associated approvals) were standardised in accordance with the CASA Risk Management Manual and that decision-making was appropriately documented. Additionally, CASA developed an ‘exemption protocol suite’ of documents, which detailed the principles, protocols and work instructions for CASA’s regulatory exemption process. CASA also completed and provided exemplar bowtie and aviation safety risk assessments using the structured process.

ATSB comment

The ATSB welcomes CASA’s revised documented regulatory exemption process. If the process is conducted as documented, including the use of a structured risk management method, this should assure an adequate level of safety is achieved and documented when approving regulatory exemptions.

Helibrook inadequate safety management

Safety issue description

Helibrook’s approved safety management system was not being used to systematically identify and manage operational hazards. As a result, risks associated with conducting human external cargo operations such as carriage of the egg collector above a survivable fall height were not adequately addressed.

Issue number: AO-2022-009-SI-02

Issue owner: HELIBROOK PTY LTD

Transport function: Aviation: General aviation

Current issue status: Closed – No longer relevant

Issue status justification: As Helibrook has ceased operation, the safety management system is no longer in use.

Response by Helibrook

Following this accident, Helibrook advised the ATSB that they had ceased operation. They further advised that their helicopter fleet was being sold and the chief executive officer/chief pilot was no longer involved with the operation.

ATSB comment

CASA confirmed that as Helibrook no longer had the required key personnel, it was considered to be suspended from operation. Under those circumstances, the operator’s safety management system was no longer in use. The identified safety issue was therefore closed as no longer relevant.- How convenient??

Have now tried to read and absorb the excessively long, overly opinionated and poorly written ATSB investigation final report: IE Fuel exhaustion and collision with terrain involving Robinson R44 II, VH-IDW, King River, Northern Territory on 28 February 2022.

Although basically following the accepted ICAO Annex 13 final report format and principles, IMO this report is designed to be complex and fractured in order to lull the reader into boredom and distraction from the some of the deep underlying practical drift issues, especially in the areas of proper regulatory oversight and surveillance.

Therefore to begin I will focus on the areas that timeline the regulator's oversight of helicopter crocodile egg collection HEC (human external cargo) operations up until this tragic and avoidable fatal accident.

In the beginning, PG 63 of the report:

..A CASA-authorised aeronautical (design) engineer first issued an engineering order approval for
installation of a hook system on an R44 helicopter in December 2007, to enable slinging of an egg
collector onto a crocodile nest to facilitate egg collection. However, the approval for fitment of the
hook system did not in itself provide approval to conduct external load operations. To make it clear
that operational approval was also required, the RFMS associated with the engineering order for
the hooks system stipulated that use of the hooks was limited to the commercial collection of
crocodile eggs in accordance with CASA-approved operational procedures.

CASA authorisation

Civil Aviation Regulations 151 and 250, which were in force throughout the 2007–2021 period of
instrument approvals, did not permit a person to be picked up or carried outside a helicopter
without CASA’s authorisation and permission. For crocodile egg collection, CASA issued
instruments to helicopter operators that authorised the pilot in command to pick up a person under
Civil Aviation Regulation 151(3) and permitted the pilot to carry that person in a harness system
attached to the R44 helicopter under Civil Aviation Regulation 250(2). Civil Aviation Safety
Regulations Part 11 applied to this authorisation. Specifically, CASR 11.055 (1)(d)20 stated that
CASA may grant the authorisation only if ‘granting the authorisation would not be likely to have an
adverse effect on the safety of air navigation’ (CASR, 2010)...

...In 2013, CASA identified that the hooks that were being used for crocodile egg collection
operations were not certified for HEC...

...Given limited time until the crocodile egg collection season started that year (December 2013), CASA approved the design engineer to continue to authorise installation of the dual hooks under the engineering order with an interim approval exempting compliance with the FAR EMI requirement until March 2014. The operation continued to be conducted in accordance with a separate CASA operational approval.

Let's now focus on the 'CASA operational approval':

(page 66)

...The first CASA authorisation instrument for R44 HEC for crocodile egg collection, was reported to
have been issued in 2007 associated with the first fitment of a hook system to an R44 helicopter
for HEC. CASA was unable to find any record of instruments issued prior to 2010 or any
documented safety case or risk assessment associated with the first instruments that were issued
for the activity.

The ATSB obtained instruments issued to several operators from 2010 to 2021 and interviewed
several CASA delegates who had approved instruments for the activity, or were involved in the
approval process from 2013 onwards.

The 2010 instrument was issued for both R44 and Bell 206 helicopters. All subsequent
instruments were for R44 (and R44 II) helicopters only. The 2010 instrument listed 20 conditions,
most of which appeared in all subsequent instruments. Included in the conditions were limitations
to the height, speed and distance the sling person could be carried. Appendix C – HEC height,
speed and distance/time conditions 2010–2021 includes a table of the HEC limitation conditions in
the instruments issued from 2010 to 2021.

For the instruments issued from 2010 to 2013 (inclusive), these conditions were:

• The person is not lifted to a height of greater than 5 metres above the ground or obstacles.
• The aircraft is not flown at a ground speed greater than walking pace when the person is
carried under the helicopter.
• The maximum distance the person is carried under the helicopter is 500 metres for each pick
up.

Request for changes to conditions

In 2013, one operator requested an amendment to the conditions, including replacing HEC height,
speed and distance limits with pilot-assessed safe height, speed, and distance. In response,
CASA asked the operator to conduct a risk assessment.

Operator risk assessment

That operator provided CASA with an assessment of risks identified for human sling operations for
crocodile egg collection. The assessment was derived from a WHNT safe work method statement
provided to all operators involved in the crocodile egg collection. The assessment detailed 7 steps
in the job sequence. For each of those, it identified ‘What can go wrong’, assessed the initial risk,
proposed control measures and assessed the resulting risk.

The job sequence ‘Lift collector and transit to crocodile nest’ obtained an initial risk rating of
‘catastrophic’. The likelihood was assessed as ‘very possible – will probably occur in most
circumstances’; the consequences were assessed as ‘extreme – fatality or multiple fatalities’.

The list of hazards for that risk included equipment failure, falling from height and external load
limitations (along with crocodile attack, adverse weather, fatigue/heat exposure/exhaustion, flora
and fauna). The risk was reduced to ‘high’: unlikely – could happen sometime, with extreme
consequences of one or multiple fatalities, with the following proposed mitigations:

• First Aid/trained personnel
• Medivac
• Pilot is spotter for people on ground, must ensure direct line of sight to human sling person at
all times
• Collection crews in 1-2 man teams – lookout
• Pre-start inspections include belly hook & longline test
• Collecting crew to inspect harnesses, helmets, radios
• Training/Experience
• Rehydration available
• Lift register

Engine mechanical failure and fuel exhaustion/starvation were not included in the hazards for the
slinging component therefore no relevant mitigations were included. Engine mechanical failure
was however identified as a hazard in the non-slinging job sequences ‘Start aircraft and take-off’,
Fly/Ferry to collection areas’ and ‘Return to base/ferry to next job’. Mitigations for engine
mechanical failure included the daily inspection, emergency training and rescue plans, adherence
to helicopter limitations, and pilot training/experience.

The CASA delegate who assessed the provided risk assessment described it as basic and the
requested condition changes were not granted. However, there was no documentation provided
that correlated the risk assessment with CASA’s retention of the conditions in the instrument. - WTD??

And so the 'regulatory practical drift' began...  

2014 and 2015
The 2014 and 2015 instruments were valid from December to the following May, consistent with
the crocodile egg collection season. In 2014, the 2013 condition that limited the HEC height to 5 m
above the ground or obstacles was amended to:

The person is not to be lifted to a height of greater than 5 metres above the ground or water. To
remove doubt this instrument does not permit lifting of a person to a height greater than 5 metres
above an obstacle. The height restriction is in reference to the ground or water in all instances.

No documented reason for amendment to the operating height conditions was provided. The
delegate who made that amendment reported that the purpose was to make it clearer and avoid
ambiguity. The delegate also amended the speed condition to be less prescriptive and provide‘flexibility to operate more safely’. The HEC speed limitation was changed from ‘walking pace’ to:

The aircraft is to be flown at speed that is considered by the pilot in command to be a safe speed,
taking into consideration the prevailing wind direction, wind speed, and aircraft performance when the
person is carried under the helicopter. Minimisation of injury to the person in the event of hook release(whether planned or inadvertent release) must be considered in the context of the total forward speedof the person over the ground. - OH MY HEAD HURTS..??

A new condition was also added in the 2014 instrument, which stated that the sling person must
be provided with a copy of the instrument and ‘made aware, in writing, that the hook system is not
certified for human use’. That condition was retained in all subsequent instruments.
2016
In 2016, the CASA delegate was invited to a demonstration of human slinging for simulated
crocodile egg collection. Following the demonstration, the height condition was amended to
provide the operators ‘some relief to be able to go over obstacles that might be in their flight path
to go from one point to another’ as follows:

The person is only to be lifted to a height above the ground or water that enables the person and
aircraft to safely traverse over natural obstacles. In all other instances, the person is not to be lifted
more than 5 metres above the ground or water. Minimisation of injury to the person in the event of
hook release (whether planned or inadvertent release) must be considered in the context of the height
the aircraft is operated above the ground or water at any particular time.

When asked how lifting the HEC above the nominal survivable height of 5 m affected the activityrisk, the delegate commented that it was not un-survivable because ‘the operator had anobligation to conduct the operation in a safe manner’. Additionally, in 2016, the 500 m distance
limit the HEC could be carried was amended to:

The person is only to be carried for the minimum distance and time required in order to safely conduct
the activity, taking the possible effects of suspension trauma on the person into consideration. To
avoid any ambiguity, the intent of this condition is that the person is not to be carried for the purpose
of positioning flights over landing sites where it would be possible to conduct the safe donning or
removal of the person from the strop used to carry the person.

In 2016, Helibrook received their first instrument for R44 HEC for crocodile egg collection. Thechief pilot had previously been involved in conducting the same operation for different AOCholders.

2017 and 2018

The ATSB obtained instruments issued to 3 operators in 2017, including Helibrook. As Helibrookwas oversighted by a different CASA regional office to the other operators, multiple delegateswere involved in the instrument approvals. (The blind leading the blind)

Late in 2016, the EMI test report demonstrating compliance of the hook system was completed.
As a result, the HEC height limit was removed from the RFMS for the hooks, which was onlyrequired to consider failure of the hook system, not failure of the helicopter and associated operational safety limitations.

A 60 kt speed restriction was included in the RFMS, based onreported feedback from an egg collector stating that was a suitable operating speed. It was noted at the time the amendments were made to the RFMS, that operational limitations specified in CASA’s operational instrument would be ‘overarching and could contain more conservative limitations’. However, when CASA asked for advice regarding limitations, the design engineeradvised that additional limitations were unnecessary as the system was now HEC compliant. - 

The 2017 delegates and their CASA subject matter experts – airworthiness/engineering and the
previous delegate – agreed that as the height limitation had been removed from the RFMS, itcould also be removed from the CASA instrument, because inadvertent release was nowextremely unlikely as the hook system was compliant. It was also assessed that there was nolonger any purpose in stipulating a speed limit because ‘at 500 ft above ground level…forwardspeed will have no bearing on the HEC’s chances of survivability’1.  Therefore, the height limitation
condition and the clause in the speed condition regarding minimisation of injury to the HEC were
removed from the 2017 instrument conditions. However, the pilot-assessed safe speed and
minimum distance conditions were retained. 1 (IE They'd be dead anway)


The delegates reported that they relied on information provided by the subject matter experts and
assessed that there were reasonable mitigations in place with the conditions. One delegate
reported that they had accessed relevant files and had conversations with other delegates. They
therefore assessed that the activity presented an acceptable risk, particularly as the instrument
was a renewal for an activity that had been conducted without accident or serious incident for at
least 5 years. - UDB!

Although the height and speed limit conditions were removed once the hooks were HEC
compliant, the instrument condition advising that the hooks were not certified for human use was
retained. The delegate reported that their understanding was that the hooks were satisfactory and
fit for purpose but not certified or approved by CASA.

The instrument delegate responsible for the instrument issued to Helibrook assessed that the
activity was high risk, but accepted by CASA. Further, they considered that the removal of the
height limitation was ‘a small change’ and nothing significant that would affect the operation.

From 2018, the instruments were issued for a 12-month period from December.

Relevant to the Operator Helibrook:

..The CASA flight operations inspector responsible for oversighting Helibrook was assigned as the
delegate for Helibrook’s instrument renewal in 2019 and 2020. The delegate assessed that the
Helibrook operations manual had reasonable procedures for the activity, the sling equipment was
approved, and the chief pilot and/or pilots involved had sling approval and relevant experience.

The delegate assessed that as it was a renewal, the procedures were in place and if they
continued doing what they were doing previously, there was probably no reason not to allow them
to continue what was an established activity. They also assessed that minimisation of exposure
was included in the operator’s procedures. The delegate did not identify any discrepancies
between the operations manual, RFMS and the instrument conditions.

In both of those instruments, CASA’s STC approval process of the hooks was underway. In
anticipation of that approval, the conditions included that the aircraft must have been modified in
accordance with the nominated engineering order for the dual hooks, but would need to be shown
to be compliant with and certified to the STC within 14 days of the STC’s approval...

...CASA advised that they could not locate any risk assessments and that
they had not conducted any specific testing or assessment of the risk profile for the activity of R44
HEC for crocodile egg collection. Specifically, CASA also advised that they had no evidence of
any risk assessments associated with the instruments issued to Helibrook between 2016 and 2021.   

CASA safety assessment assumptions??

Although they reported not having seen a CASA risk assessment for the activity, the involved
delegates assumed that a safety case would have been provided with the first operator’s request
for approval for the activity (sometime prior to 2013) and that had been assessed and accepted by
CASA. The activity was understood to be high risk, but delegates believed that CASA accepted
that risk level. In particular, as the 2013 instruments were signed by a senior CASA manager, this
was interpreted as an endorsement that it was appropriate to continue issuing the approvals...

..All the operators conducting crocodile egg collection each season received essentially the same instrument, although some conditions varied from one year to another. Prior to issuing Helibrook’s first instrument in 2016, a
CASA inspector verified that the operator had:

• a procedure for conducting the activity
• appropriately experienced personnel
• relevant documentation and sling equipment.

The Decision and the RMP??

In August 2013, a CASA project was initiated to consider existing HEC regulations and propose amendments to Civil Aviation Order (CAO) 29.6, which only applied to non-human sling operations. The project identified that permissions being issued by CASA regional offices were not issued on the basis of a risk assessment or reflective of international standards. Specifically, in the US, United Kingdom and Canada, HEC was not permitted with piston engine rotorcraft and, CASA had assessed that the use of piston engine helicopters increased the risks to HEC compared with turbine engine rotorcraft. Additionally, in 2013, helicopter operators involved in the powerline industry had approached CASA for HEC approval using turbine engine rotorcraft, consistent with international requirements.

As a result of the project, in October 2013, the then CASA Director of Aviation Safety (DAS) signed an internal minute that recommended CASA restrict HEC operations to the following requirements:

• single engine turbine powered rotorcraft with a usage monitoring system
  
• out of ground effect hover performance with a performance buffer
  
• restrictions on who could be carried
  
• an attachment means certified for the carriage of humans.
  

The minute also recommended that the proposed standard be communicated to CASA field officers for consideration in all authorisation/permission approvals, while the proposed amendment to CAO 29.6 to reflect the policy was being drafted.

As a component of the project, a CASA risk workshop on crocodile egg collection using HEC was held on 20 November 2013. While no minutes were recorded from the meeting, a draft risk management plan (RMP) provided to the ATSB formed the basis of the discussions.

Risk management plan

The stated purpose of the RMP was:

to examine the risk indicators in HEC operations in a piston engine rotorcraft in an Australian operational context of crocodile egg harvesting.

The RMP was drafted by a senior standards officer with significant helicopter and HEC expertise using a CASA general aviation operations template. The scope included that the assessment:

…considers isolated factors specific to piston engine rotorcraft, single engine turbine rotorcraft and multi-engine turbine rotorcraft. Risks relevant to the task of HEC beneath any rotorcraft are examined for context and amplification. A limitation to scope is that the cumulative effect of the individual risks should they be realised in combination is not considered. It would be prudent to conduct analysis of this eventuality should the risk assessment be furthered.

The assumptions listed in the RMP were:

• Permitted operators must have a proven safety and compliance record underpinned by a robust Safety Management System that could be leveraged for continued operation with strict regulatory oversight.
• CASA will exercise additional oversight of approved operators should an approval be granted that is strictly limited in scope and will result in removal of the operators [sic] approval should any non‑compliance be identified.
• The risk exposed by utilizing an external load assembly not approved for HEC provides a residual risk rating that is acceptable for a finite period of six months.

The overall operational risk of the activity was assessed with an initial risk rating of high (7), which ‘needs senior management attention’, and the residual risk (with controls in place) of medium (5), requiring ‘management responsibility’.

CASA’s General aviation operations group risk matrix utilised to assess the operational risk is depicted in Appendix B – CASA operational group risk matrix (2013).

Extreme and high risks were required to be reported to senior management and have detailed treatment plans, ‘which reduce the risk in accordance with the ALARP [as low as reasonably practicable] principle’. CASA AC 138-05 – Aerial work risk management defined ALARP as ‘the point where the costs of introducing further safety measures to lower a risk outweigh the safety benefit. However, a risk should be tolerated only if there is a clear benefit such as a compelling operational need’ (CASA, 2022).

The broad risk categories considered in assessing the risk associated with HEC operation were:

• engine failure/malfunction inside the H/V envelope with HEC attached
  
• insufficient excess power available for role and environment
  
• equipment/hardware failure of rotorcraft system or subsystem
  
• human error while undertaking HEC operation.
  

Potential risk controls were:

• preference of multi engine turbine rotorcraft with [one engine inoperative] OEI accountability
  
• preference to single engine turbine rotorcraft
  
• usage monitoring systems of pertinent parameters
  
• equipment standards to HEC design criteria
  
• limitation of exposure measured in time, distance, speed and height [above ground level] AGL
  
• CASA increased surveillance of operations whilst under limited conditions
  
• CASA mandated minimum experience level and qualification to conduct HEC
  
• increased engine and critical component inspection criteria
  
• mandated excess power margin requirements for [hover out of ground effect] HOGE conditions
  
• limitations in environmental conditions including wind azimuth, velocity, humidity.
  

The RMP identified 26 individual hazards, all of which were assessed as initially not ALARP. Some of the documented hazards were linked to the R44 POH and Robinson Safety Notices. Proposed operational mitigations included additional regulatory oversight to ensure procedures were followed and maintenance/overhaul requirements were adhered to.

For the hazard of single engine piston rotorcraft engine failure while operating in the H/V envelope, the likelihood was assessed as rare – 1 in 10,000 to 1 in 100,000, with severe consequences – multiple life-threatening injuries/less than 10 fatalities, and an overall medium risk. Suggested mitigations to reduce the residual risk, still rated as medium, included:

• minimise exposure time for HEC and enforce conservative limits of distance, height and time
  
• require engine usage monitoring system
  
• use fuel injected models only
  
• require single engine turbine to reduce failure rate, or multi-engine rotorcraft with one engine inoperative accountability; or in consultation with the manufacturer increase inspection requirements including engine compression checks, and reduce overhaul period.
  

There was no assessment of the hazard of fuel exhaustion, but fuel starvation or contamination was assessed. For these, the initial risk was assessed as unlikely, and the consequences were severe with an overall high risk rating. With mitigations including fuel checks, minimum fuel requirements, fuel usage policy and turbine engine, the residual risk was medium, requiring CASA management responsibility.

The author of the RMP subsequently advised the ATSB that the omission of fuel exhaustion as a hazard was unintended, and that the proposed mitigations were also applicable to fuel exhaustion. 

CASA’s Flight Standards Branch advised the ATSB that the RMP was never finalised, and the risk controls proposed to mitigate the risks of continuing R44 HEC for a further 6-month period were not implemented. The draft RMP was however used by CASA Flight Standards Branch to propose HEC standards, first for an amendment to Civil Aviation Order 29.6, which was subsequently discontinued (in 2016), and then for the development of CASR Part 138.

CASA also advised that the RMP was used to consider the potential viability of allowing single engine piston helicopter HEC operations based on an equivalent level of safety. This would have required demonstration that the piston engine helicopter had a similar in-flight failure rate as a turbine engine helicopter with a usage monitoring system. Members of CASA’s Flight Standards Branch presented this option to operators in 2014, however, no operator attempted to demonstrate this equivalence.

All good stuff and sad that the RMP was discontinued but why wasn't it referred to as a safety risk mitigation reference for all the R44 HEC operational instruments that were renewed by CASA delegates from 2013 onwards??

Response to the proposed changes

The design engineer responsible for the hooks system responded to CASA’s letter on behalf of operators that conducted crocodile egg collection. The response disputed the safety data referenced in CASA’s letter, requested coordination between CASA’s certification/airworthiness and operations personnel and continued R44 operation for one more season to allow operators time to address the proposed requirements.

In response, a CASA regional manager?? made a documented recommendation to a senior manager?? within CASA that R44 HEC operations continue. The recommendation outlined CASA’s authorisations of R44 HEC operations for crocodile egg collection, the 2013 DAS decision to establish formal policy (including the use of turbine powered rotorcraft for human sling load operations) and that since that decision, CASA had undertaken work regarding the appropriateness of piston engine rotorcraft to carry human external cargo.

The recommendation also advised that that operator had requested reissue of the authorisation to continue to operate until CAO 29.6 changes were finalised. In support of the request for continued R44 HEC operations, the design engineer provided their comparative analysis of Bell 206 (turbine helicopter) and R44 engine failure data. Additionally, the regional manager proposed that extra conditions be included in the instrument to ‘mitigate those risks further’. Key additional conditions from the precedent instrument (which was valid from 2 December 2011 to 31 December 2013) were:

• the hooks are to be certified for use in human sling load operation
  
• engineering orders must confirm that all things attached to the hook systems are fit for purpose
  
• the aircraft is to be operated in accordance with the approved FMS
  
• daily inspection includes sling system/equipment
  
• the pilot is required to verify the engine is capable of normal rated power with no defects evident and to certify this on the maintenance release
  
• only persons employed or contracted for egg collection can be carried.
  

The reasons given for the recommendation were that:

• the overall risk to safety of the egg collector could be reduced by the use of the R44 aircraft type
  
• other operational activities permitted by CASA possessed ‘equal hazards and risks, such as mustering operations, night agricultural operations, and parachuting activities’.
  

The senior manager agreed with the recommendation and signed instruments authorising continued R44 HEC operations for crocodile egg collection to the end of April 2014 for 2 operators.

The CASA delegate who approved the following year’s instrument assumed that one reason the 2013 instruments were signed by a senior manager was to demonstrate that CASA senior management was aware of the operational approvals process and was satisfied it was appropriate to issue the instruments.

So after the DAS minute the end was nigh for the R44 (Croc Egg Collector) HEC operation, yet a 'Regional Manager', with the support of a 'Senior Manager' (negating the 'High Risk' requirement), breathed life back into at least another season of R44 croc egg collection. However, as will be seen the practice continued unabated till at least the final introduction of Part 138 on 2 December 2021.

Proposal to discontinue CAO amendments

In 2016, the then DAS agreed with a proposal from CASA Flight Standards Division to close the existing project to amend CAO 29.6, as it had been ‘superseded by Part 138’. The finalisation of Part 138 was reported to be ‘imminent’, with a proposed effective date of September 2018. The proposal included that crocodile egg collection would ‘continue as per current exemptions until such time as Part 138 is made and the regulation commences’.

So consequently the 2013 HEC project, DAS decision and associated RMP were shelf-wared and ignored, while the pending introduction of Part 138 dragged out till 2 December 2021...

Next - What the HEC??

Briefing note July 2021

In July 2021, an internal briefing note to a senior CASA manager stated that:

When Part 138 of CASR commences on 2 December 2021, operators conducting crocodile egg collection operations will need to replace their Robinson R44 helicopters with a helicopter that has improved reliability.
The briefing note outlined the risk assessment and subsequent work, which had concluded that HEC operations were very high risk for the sling person. It stated that the risk could be substantially mitigated through the use of a turbine engine helicopter with a usage monitoring system. Additionally, the hook system needed to provide redundancy in the case of failure of the hooks/system.

The Background section of the briefing note included that CASA’s previous permission instruments had not been issued on the basis of a risk assessment, and that the risk had been assessed in 2013 as unacceptable without mitigation. Further, that CASA’s authorisation of R44 HEC operations was not reflective of international standards and significantly differed from the FAA, Transport Canada and EASA. At that time these organisations generally required multi turbine engine helicopters with one engine inoperative accountability for commercial operations, with the use of high-reliability single turbine engine helicopters permitted for limited specified operations. 

The Way Forward section of the document noted that some helicopter operators were already conducting powerline maintenance work using a single engine turbine helicopter for HEC, based on the CASR Part 138 standards.

 

Transitional regulations

At the time of the accident, Helibrook and other operators were conducting crocodile egg collection under their AOC as an aerial work operation. From 2 December 2021, crocodile egg collection required a CASR Part 138 Certificate (instead of an AOC) to authorise the operation. The crocodile egg collection operation (carriage of a person outside a rotorcraft) was categorised as an aerial work class D external load operation under CASR Part 138.[24] Chapter 15 of the Part 138 manual of standards (MOS) – Rules for external load operations, applied to the activity.

Section 15.06(3)(e) applied to rotorcraft that cannot hover out of ground effect with one engine inoperative, requiring section 9.05(b), ©, (d) and (e) of the MOS to be complied with. This required the rotorcraft to have:

a turbine engine
a usage monitoring system
control to be maintained in all phases of flight in the event of a hydraulics failure or alternatively dual hydraulics
redundant means of controlling fuel flow to the engine.
CAR 151 and 250 were repealed on 2 December 2021. An authority under CAR 151(3) and a permission under CAR 250(2) applied to CASR Part 138. The Part 138 requirements were more onerous than the existing instrument issued to Helibrook for crocodile egg collection, which permitted use of a piston-engine helicopter without a usage monitoring system. In order to permit continued egg collection using the R44 an exemption was granted under Division 11.F.1, including CASR 11.170(3), which stated:

In making its decision, CASA must regard the preservation of a level of aviation safety that is at least acceptable as paramount.

Despite this the operator was reissued it's R44 HEC instrument:

Despite the intended safety improvement associated with the introduction of Part 138 requirements, Helibrook’s instrument was issued on 9 September 2021, with a 3‑year validity period. Under the transitional legislation, it would cease at the earliest of the:

• expiry of the instrument (31 December 2024)
  
• second anniversary of the instrument commencement (7 September 2023)
  
• day the operator’s AOC expired (31 July 2022, extended to July 2023 after the accident).
  

Considering these criteria, Helibrook would be required to comply with CASR Part 138 and Part 138 MOS when its AOC expired.

---

Helibrook’s 2021 instrument

The 2020 instruments were valid until 31 December 2021. On 2 September 2021, the Helibrook safety manager emailed CASA’s Regulatory Services requesting a renewal of the instrument with the 2020 instrument attached to the email. After payment, the task was assigned to the delegate on 9 September 2021, who recalled that it was relatively urgent. The delegate reported being unaware of the history of the authorisation, but was aware of the general risk of the operation and that it had been assessed by multiple sections within CASA.

The delegate reviewed the file relating to the most recent instruments and emailed the previous approver asking whether there were any concerns regarding reissue of the instrument to Helibrook. The previous approver advised that:

• the STC for the hooks had been issued on 30 July 2021
  
• there had been no changes to Helibrook’s equipment or procedures that they were aware of
  
• CASR Part 138 was not yet in force
  
• considering the above, they saw no reason why a new instrument should not be issued.
  

They also commented that they did not believe there was a compelling statistical argument to justify the higher cost of a turbine engine helicopter that would be required under Part 138.

The delegate then signed the instrument on 9 September 2021 with an expiry date of 31 December 2024. There was no change to the conditions from the previous year’s instrument. The references to the now redundant EO were not removed. Condition 23 stated that when the STC is approved, ‘all aircraft previously certified to the [engineering order] EO will be shown to be compliant with and certified to the STC within 14 days of the STC being approved, after which time aircraft certified only to the EO may no longer undertake this work’. Helibrook did not update the hook installation on VH-IDW to the STC. The delegate reported that they were unsure about whether the hooks had been certified. The delegate also reported being unaware of the implications of the impending Part 138 requirements when they issued the instrument for a 3-year period.

At the time of the accident, VH-IDW was operating under CASA Instrument CASA.CARRY.0163 Revision 1, issued to Helibrook and dated 7 September 2021 (2 days prior to it being assigned to the delegate).

There were 34 listed conditions that Helibrook and the pilot in command were required to comply with (Appendix D – Instrument conditions). There was no limitation specified for the HEC carriage height. Key conditions discussed previously included:

• The pilot in command and sling person were required to have completed a course of training for the activity promulgated in the helicopter operator’s operations manual. The operator’s training course was to include not less than 1 hour of flight time and 1 hour of ground instructional time.
  
• A thorough pre-flight briefing was to include actions to be taken by crew members during possible emergencies – the briefing was to be conducted in accordance with the briefing procedures in the operations manual.
  
• The helicopter was required to be compliant with the STC SVR 541 and to be operated in accordance with the FMS, which details normal and emergency procedures associated with the activity.
  
• The pilot and operator were required to comply with the relevant procedures in the company operations manual.
  
• The pilot was required to have continuous and clear radio communications with the sling person throughout.
  
• The pilot was required to fly the helicopter at a ‘safe speed’ and to carry the sling person ‘for the minimum distance and time required in order to safely conduct the activity’.
  
• The sling person was required to wear an Australian Standard helmet (‘appropriate to the risks encountered during the activity’).
  
• Prior to commencement of the activity each day, the pilot was required to verify that the engine was producing normal rated power output, and that no defects were evident which could lead to power reduction during those operations.
  
• The sling person must be made aware, in writing, that the hook system is not certified for human use.
  

All too little, too late for Chris 'Willow' Wilson...
  
TBC...P2 

[Peetwo]

Su_Spence breach of statutory duty and negligence timeline - Part II

The following is a summary of CASA's  normalised deviance of the approval process for HEC sling crocodile egg collecting from 2007-2023 (pg 90 of the report):

The first approval instrument to conduct HEC operations for the purpose of crocodile egg collection was reported to have been issued in 2007, and subsequently reissued generally on an annual basis. CASA was unable to locate records of instruments issued before 2010, any assessment as to whether the authorisation was likely to adversely affect safety, or how the imposed conditions mitigated the risks. The first instrument obtained by the ATSB was for 2010 and listed 20 conditions. These included a requirement that hooks were fitted to the helicopter under an appropriate design approval and limitations to the height, speed and distance the sling person could be carried.

The CASA delegates who issued authorisation instruments for R44 HEC for crocodile egg collection from 2013–2021 incorrectly assumed a risk assessment had been performed when the first instrument was issued. The delegates also assumed previous approvals meant that the risks of HEC operations had been assessed as acceptable by CASA, and that the conditions included in the instrument mitigated the risks. However, none of the delegates had sighted a risk assessment for the activity, nor did they conduct one, including when changing or removing instrument conditions. Additionally, although the instrument only permitted operators to conduct HEC if there was an overall safety advantage in reducing the risk of crocodile attack and heat illness, CASA did not ensure that the operators had a process for assessing the relative risks.

In the absence of a formal risk assessment process, delegates based their approval of the activity and the imposed conditions on the advice of CASA flight operations and airworthiness inspectors, and a reasonableness test. Additionally, delegates considered the instruments were reissues of an existing approval even when removing or amending conditions. Therefore, if there were no changes to procedures and no accidents, they assessed that there was no reason not to issue an authorisation, as the level of safety was considered not to have changed.

A draft HEC in piston engine rotorcraft risk management plan (RMP) using a CASA general aviation template was prepared by CASA Flight Standards Branch personnel and presented to CASA executive in 2013. The RMP and associated template was a formal risk assessment tool. The RMP assessed that HEC operations in single engine piston (R44) and turbine helicopters was an unacceptable risk without mitigations to improve helicopter reliability, and speed, height and duration limitations for carrying the HEC.

The RMP formed the basis of CASA’s proposed standard to cease issuing approvals for HEC with the R44 and to require a single engine turbine helicopter with a usage monitoring system. This was due to the associated higher risk of in-flight power loss and additional failure modes of an R44. The turbine engine requirement aligned with US and European regulations and was to be included as an amendment to Civil Aviation Order 29.6. That amendment was abandoned in 2016, due to planned implementation in 2018 of the same ruleset incorporated in Civil Aviation Safety Regulations Part 138. However, regulatory change took longer than anticipated, and Part 138 was implemented in December 2021. None of the delegates involved in approving instruments after 2013 reported having seen the RMP.

As the instrument conditions were described as risk mitigations, a formal risk assessment would have enabled delegates to quantify the change in overall risk associated with changes to, or removal of, conditions. Without a formal risk management process, CASA delegates were unable to show in a structured way that an authorisation did not adversely affect safety or that the conditions included in an authorisation were sufficient to achieve the required level of safety.

So many opportunities to shut down the extreme high risk aerial work activity of crocodile egg collection in piston single-engine R44 helicopters. Yet it didn't happen due to ignorance and bias with multiple delegates, a Regional Manager and their ability to subsequently persuade a 'Senior Manager', contrary to a DAS direction, to sign off on a dodgy submission to issue a amended instrument, that was subsequently sustained (with minor alterations) for the better part of a decade?? - 

The totally disconnected (from all reality) justifications from the submission: 

• the overall risk to safety of the egg collector could be reduced by the use of the R44 aircraft type
  
• other operational activities permitted by CASA possessed ‘equal hazards and risks, such as mustering operations, night agricultural operations, and parachuting activities’.
  

   
Besides the 'parachuting activities', where the individual risk is accepted and the operational high risk is lessened every second the aircraft gains altitude, the other ops involve a single flight crew member, who is aware of the high risk nature of the activity and how best to mitigate the operational risk. 

It is interesting to note that in 2015-16 both the aerial ag and mustering ops sectors had worked with CASA to produce proactive sector risk profile documents, EG: https://auntypru.com/wp-content/uploads/...sector.pdf

...Sector risk profiling identifies sector specific risks and develops a deep understanding of the effects of risks that sector participants must address in order to maximise their aviation safety performance. Effective risk management also makes a significant contribution to an operator achieving its commercial objectives. The sector risk profiling process adopts the CASA Risk Management Framework, which is based on AS/NZS ISO 31000:2009 Risk Management – Principles and guidelines, to identify, assess and treat the risks that must be managed by sector participants.

A sector risk profile provides the sector participants and CASA with an opportunity to understand the effects of aviation related risks on the sector and how the level of risks can be reduced and managed utilising an approach that monitors the implementation of risk treatments by sector stakeholders, including CASA, as well as evaluating the effectiveness of the risk treatments through a set of safety performance indicators. The sector risk profile also provides an opportunity for authorisation holders in a sector to manage the effects of risks listed in the sector’s risk register.

The successful development of a sector risk profile relies on industry participation in identifying hazards, associated risks and developing treatments which are not only feasible but also effective in delivering safe outcomes. It is in this regard that I would like to thank the principal contributors from the aerial mustering sector namely Mr John Armstrong, Mr Craig Crumblin, Mr David Fox, Mr John Logan, Mr Dick Tully, and Mr Grant Wellington, for giving up their valuable time to attend workshops, provide commentary on documentation and demonstrating a complete dedication to building a risk profile for the sector.

Safe Flying

Mr Mark Skidmore, AM

Chief Executive Officer and Director of Aviation Safety

---

  
Some other additions to the BSDNT timeline for around 2016 onwards:

Outback Wrangler star Matt Wright’s company under investigation for incident

..Outback Floatplane Adventures is owned by Mr Wright and business partner Troy Thomas and offers people the opportunity to see the Top End from airboats, choppers and floatplanes...

---

1 May 2018
Via FB: https://www.facebook.com/watch/?v=1464069073739079
Exciting news!! After 5 years of developing the Northern Territory’s Number ONE tour, my business partner Troy Thomas has taken over the tour company Outback Floatplane Adventures - it’s a cracking adventure so make sure you check it out if you come north! I’ll still be running my private and corporate tours and focusing on filming more seasons of Outback Wrangler. So watch this space ???

---

Relevant reference:  Su_Spence timeline of negligence and duplicity on Top End Robbo and Tourism Ops!! 

Plus 2020 onwards:

CASA gave Matt Wright exemption before Chris Wilson’s fatal chopper crash


The Civil Aviation Safety Authority granted Netflix star Matt Wright and two of his mates ­exemptions that allowed them to collect crocodile eggs with someone hanging from their helicopters – after its chief executive and board members received a private demonstration – just months before the fatal chopper crash that killed Chris Wilson.

New flight operations rules, ­effective from December 2021, stipulated that only turbine-­engine-powered helicopters were permitted to carry a person externally for sling operations.

Despite this, in September 2021, CASA granted Wright and pilot Michael Burbidge an exemption allowing them to continue carrying crocodile-egg collectors beneath their piston-engine-powered Robinson R44 aircraft for ­another three years.

In February last year Wilson – who starred on Outback Wrangler and Wild Croc Territory – was killed when the Robinson R44 Raven II he was slung beneath crashed in a remote part of West Arnhem Land during an egg-collecting mission. Pilot Sebastian Robinson was critically injured.

The Australian Transport Safety Bureau’s preliminary ­report revealed the chopper’s ­engine had stopped before the helicopter hit the ground.

The destroyed chopper was owned and operated by Wright’s company Helibrook and contracted to Mick Burns’ company Wildlife Harvesting NT.

Shortly before the exemptions were granted, Mr Burns and Wright met CASA chief executive Pip Spence and board members Tony Matthews, Michael Bridge and Elizabeth Hallett in Darwin.

The CASA executives had travelled to the Territory in June 2021 for a safety forum, regular board meeting and industry ­engagement events. CASA said it fully-funded its employees’ travel.

While in Darwin, Ms Spence, also director of aviation safety, and her three board members visited Mr Burns’ business Crocodile Farms NT where they were briefed on its operations and how the looming new flight rules would affect its ability to collect crocodile eggs.

Celebrity croc-wrangler Wright then took the CASA CEO and Board members for a flight on one of his Bell choppers to see the scale of the company’s operations and the remote environment in which egg collection is undertaken.

The following month, CASA granted another of Burns’ companies, Porosus, a Supplemental Type Certificate allowing it to use dual cargo hooks for human external cargo operations on Robinson R44 and R44 Raven II helicopters for the purpose of crocodile-egg collecting.

A couple of months after that, CASA granted Helibrook and Mr Burbidge’s company, Northshore Holdings NT, an exemption ­allowing them to collect crocodile eggs via a sling person.

The authorisation was subject to many conditions, which included fitment of dual external cargo hooks under the certificate issued to Burns.
Among its 33 conditions, the sling person must carry a “readily ­accessible harness knife capable of cutting the lifting strop or harness in an emergency”. Also that the sling person “must be made aware, in writing, that the hook system is not certified for human use”.

CASA this week confirmed that Robinson R44 aircraft “can no longer be used for this kind of operation” under Civil Aviation Safety Regulations.

“Transitional arrangements vary between operators based on when an approval was granted but the longest an approval could be used is up to two years after it was made,” a spokesperson said.

While the exemptions granted to Wright and Burbidge in September 2021 state they will not be ­repealed until September 2024, CASA told The Australian their exemptions will cease after two years.

Since Wilson’s death, NT WorkSafe has prohibited the practice of collecting crocodile eggs from the wild by transporting workers suspended from a helicopter via a sling.

CASA board member Mr Bridge also sits on the Northern Territory Tourism board of commissioners alongside Mr Burns.

Tourism NT said it had no knowledge of, or involvement in, CASA’s visit. Wright declined to comment and Mr Burns, who is a­ ­director of Crocosaurus Cove and owns the Darwin Crocodile Farm that houses about 70,000 salt­water crocodiles, did not respond to requests for comment.

Plus additional reference:  Dear Miniscule - We sent you the lifejackets??

Next: S is for? - SMS

  

Helibrook inadequate safety management

Safety issue number: AO-2022-009-SI-02

Safety issue description: Helibrook’s approved safety management system was not being used to systematically identify and manage operational hazards. As a result, risks associated with conducting human external cargo operations such as carriage of the egg collector above a survivable fall height were not adequately addressed.

---

Response by Helibrook

Following this accident, Helibrook advised the ATSB that they had ceased operation. They further advised that their helicopter fleet was being sold and the chief executive officer/chief pilot was no longer involved with the operation.

ATSB comment

CASA confirmed that as Helibrook no longer had the required key personnel, it was considered to be suspended from operation. Under those circumstances, the operator’s safety management system was no longer in use. The identified safety issue was therefore closed as no longer relevant.

The addressee of the safety issue may be 'no longer relevant' but the subject of why the CASA approved SMS was not..
"was not being used to systematically identify and manage operational hazards"...remains IMO a very relevant question. It is also fascinating to learn how it was possible that an operator, with a Chief Pilot having such a chequered regulatory non-compliance past, was actually granted a SMS in the first place??

From page 55 of the report:

..Prior to holding the chief pilot role, the Helibrook CEO had been subject to CASA enforcement action. As a result, CASA imposed a variation on the pilot’s helicopter licence. The variation required the CEO to attend aviation theory remedial training and testing, and complete four 6‑monthly flight reviews with a CASA-approved examiner. These were aimed at ensuring ongoing proficiency in making appropriate safety judgements.

The CEO reported completing the first of those flight reviews and aviation theory training on 6 July 2019. On the same day, the CEO submitted an application to CASA for approval to become Helibrook’s chief pilot. The applicant’s previous breaches meant they did not meet one of the criteria for the chief pilot appointment, which required the person to have ‘maintained a satisfactory record in the conduct or management of flying operations’. CASA offered the applicant the opportunity to demonstrate an acceptable means of compliance with that requirement and submit a safety case stating how they would manage the risks.

Having provided a response to CASA, the chief pilot applicant was required to conduct 2 flights with a CASA flight operations inspector and complete associated ground activities. The CEO conducted the first CASA assessment flight on 6 August 2019 and was assessed satisfactory. The activities assessed were a charter flight and simulated crocodile egg collection. The examiner identified some gaps in knowledge of recent legislation, which the applicant was reported to be working to address. The examiner’s notes described an experienced pilot with a good safety focus.

The CEO’s second chief pilot assessment flight and ground activity was conducted on 25 November 2019. The examiner commented that the CEO demonstrated the ability to supervise and mentor other pilots and was assessed as suitable for consideration for appointment as chief pilot of Helibrook.

CASA subsequently approved the CEO as Helibrook’s chief pilot on 20 January 2020. Additionally, the CEO was provided with an exemption removing the requirement for the previously imposed 6-monthly flight review checks. As part of the process for the CEO to conduct the chief pilot role, Helibrook introduced a safety management system (SMS) and appointed a safety manager.

Safety manager

The safety manager was recruited by the Helibrook CEO in August 2019. The safety manager was also assigned the roles of operations manager and drug and alcohol management plan (DAMP) officer for Helibrook. Apart from a short period in 2020, when the safety manager worked for Helibrook in the Northern Territory, including as a helicopter charter pilot, the safety manager lived interstate and conducted the safety manager, operations manager, and DAMP officer roles remotely. - Hmm...can't imagine why that might be a problem administering his key responsibilities (see below)??

Documented key responsibilities of the safety manager included:

• maintaining the safety management system and ensuring it was relevant to the operations
  
• conducting hazard and risk identification
  
• conducting incident and accident investigations.
  

Safety management system

Overview

Attributes of a safe organisation include a healthy safety culture with appropriate risk management processes, which achieves safety objectives through internal responsibility rather than relying on regulatory compliance (CASA, 2019). The International Civil Aviation Organization (ICAO, 2018) defined an SMS as:

A systematic approach to managing safety, including the necessary organizational structures, accountability, responsibilities, policies and procedures. 

It is designed to continuously improve safety performance through the identification of hazards, collection and analysis of safety data and safety information, and continuous assessment of safety risks. An SMS seeks to proactively mitigate safety risks before they result in aviation accidents and incidents.

The Helibrook SMS manual version 1.0 was issued on 1 August 2019 and accepted by CASA on 22 November 2019. Although not generally required by CASA regulations at the time, it was introduced to demonstrate a commitment to safety and thereby aid in obtaining CASA’s approval of the chief pilot. The SMS manual outlined the company’s safety policy, objectives, and responsibilities for supporting the SMS and reporting of incidents, risks and hazards. It stated:

HELIBROOK will identify hazards and safety risks to minimise risk to innocent people, clients, contractors, employees, other airspace users and aircraft. It will also maintain the health of all stakeholders, and continually improve safety; these goals will be accomplished through a Safety Management System (SMS).

Helibrook’s SMS manual stated that it was to be updated annually, by the CEO in collaboration with the safety manager, and that safety meetings were to occur monthly and involve the safety manager, CEO/chief pilot and HAAMC.

   
All sounds good so far on paper but what about in practice? - Read onwards from pg 56 'Safety risk management'

Relevant extracts:

The following 2 lists are relevant to this investigation:
Helicopter:
(a) Preflight checklist
(b) Safety equipment – EPIRB, helmets, life jackets, satellite phone and flares
© Equipment lists, equipment and checks
(d) Fuel
(e) Inspection – MRs
(f) Maintenance and status
(g) Inspection and status
(h) Time to rebuild/overhaul
(i) Communications – headsets/radio
(j) Weight/centre of gravity
(k) Fuel margins and range limits
(l) Sling Equipment / Harness equipment PPE
Egg collecting:
(a) Crocodile activity
(b) Terrain
© Weather
(d) Pilot and crew performance
On 30 September 2019, in response to a request from CASA, the safety manager identified 13 hazards ‘that have the potential to cause harm to pilots and passengers’ and proposed actions to mitigate associated risks. None were associated with crocodile egg collection operations. - Hmm...maybe the Safety Manager regarded the croc collector as human external cargo?? 

---

Under 'Risk assessment':

The Helibrook operations manual standard operating procedure for crocodile egg harvesting included that in the event of an aircraft failure:

• the sling person must have a clear understanding of the risk and implications of such an emergency
  
• the risk of injury will be reduced providing all height and speed limitations are adhered to
  
• prior to slinging, the pilot must advise the sling person of the high risk nature of the operation and what steps shall be taken to reduce the risk.
  

Finally (try not to ROFLMAO), here is the historical summary of the operational reality of CASA's approved Helibrook SMS...

Helibrook’s safety management

Helibrook’s SMS manual had not been amended since initial issue and no meetings had been conducted since the introduction of the SMS. The safety manager described their role as ‘lacking’ and reported that most of their time was devoted to managing day-to-day operations (in their other role as Helibrook’s operations manager).

The safety manager also described the Helibrook hazard register as ‘a bit lacking’ - , with many of the listed items not actually hazards. Additionally, there was no assessment of risks, controls or mitigation strategies. Helibrook did not have or maintain a formal risk register, or any alternate means to track and identify hazards and associated controls for their operation. The safety manager also reported that no risk assessment had been conducted of any of Helibrook’s approved activities, including crocodile egg collection (an activity which the safety manager had not actually observed). The CASA instrument that approved human external cargo operations stipulated that human slinging could only be conducted if it was assessed as reducing the risk of heat exhaustion and/or crocodile attack. Despite that, there was no documented means of assessing the relative risks.

Safety equipment, maintenance and time to rebuild/overhaul were listed on the hazard register relating to ‘Helicopter’, however no risks had been identified with VH-IDW. The safety manager also reported being unaware that VH-IDW’s ELT was not installed.

The safety manager described Helibrook’s reporting culture as ‘not great’, with only one incident in Helibrook’s safety reporting system – a hard landing involving VH-XHB, which occurred on 30 August 2020, while the safety manager was at the site. In relation to that occurrence, the safety manager submitted an incident report to ATSB on 1 September 2020. -

The report stated the pilot was the only person on board at the time of the accident. However, the ATSB obtained footage taken by one of 3 passengers on board at the time. The safety manager was nearby at the time of the accident and, despite the detail on the incident report, reported being unaware how many people were on board. The safety manager was also the Helibrook DAMP officer and had not requested drug and alcohol testing of the pilot following that incident, as they did not think the incident was sufficiently serious to warrant it. In response to that incident, the safety manager reported proposing a windsock be put in the area to assist pilots identifying the wind direction, as misidentification of the wind direction was assessed as a factor contributing to the incident. - UDB!

The safety manager did not conduct an internal investigation into the accident involving VH‑IDW and several months after the accident reported that they did not know what happened, had not seen the aircraft or been able to obtain any information about it. As the DAMP officer, the safety manager had also not requested testing of the accident pilot. - UDB![/color]

Read it and weep! -

S is for? - Surveillance This is an easy one (IE refer to the 'Contents' [pg v - vii of the report]): According to the ATSB AO-2022-009 Final Report there is no relevant section or reference applicable to regulator surveillance activities in regards to rotary wing HEC (crocodile egg collecting) AOC approvals between 2007 and 2023. Nor is there any indication that surveillance had been conducted of the operator Helibrook?? -

MTF...P2

[Kharon]

Warning – Crankygram follows:-

But; Curious and Curiouser.

May need some 'expert' help to put a name to the subject matter of this wee ramble; but, the 'notion' stands the test of WTD. Best I step it through to assist with not only a definition; but an explanation.

Much attention is being given to the 'Croc – idiot' saga; that is (IMO) a distraction away from the deeply seated, underpinning 'safety' narrative. The events in Broome, WA define an under laying 'ethos' (for wont of better) of Cavalier attitude and some disinterested 'surveillance' of operational data, incident and 'accident'. The 'tale' which kicked off this line of 'examination' is to satisfy the ever present curiosity bump.

This is next is 'paraphrased'. No doubt the actual story can be found within the mountain of 'data' surrounding the Broome and Croc saga. Plenty of that to go around. One tale grabbed my attention; an exemplar, if you will. It seems our 'hero' in Broome, a private pilot with no AOC answered a 'med i-vac' call out; an elderly lady, on a boat was 'unwell' and in need of medical treatment. Urgent enough to warrant being air lifted - from the boat to land based 'medical assistance'.

Now, any medical transfer of patients is usually highly coordinated; pilot and nurse as a minimum; ambulance or 'patient transfer' on tap, ready to meet the flight and take the patient to the medical assistance required. Always. Even the transport of ambulatory patients is carefully 'managed' and coordinated from the initial 'call-out' to  hand off. Watch any 'you-tube' RFDS video and see how carefully the operation is managed.

So, back to 'old mate' sat at Broome; somehow – wind of the need to 'transport' an elderly lady off the boat to medical assistance reaches his ears. Our Private pilot launches on a 'rescue mission' – finds the boat. Lands on the pad, puts our sick lady into his chopper and departs the fix. Not too much later out pilot lands at his home and ensconces the 'patient' in his lounge room, to wait for further transport to wherever she felt assistance could be provided. Then, an invoice was sent (and paid) for this 'service'. No folks, not making any of this up at all.

But, put this event aside; just for a moment, and consider how, in any operational or 'legal' way this event did not have the safety 'watch-dogs' howling at the fence? Crazy stuff right enough; but there is a more sinister side to this event. What on earth prompted (supported) the belief this man had that he could actually not only conduct this operation, get away with doing it and charge the 'patient' for the service?

It begs many questions of our 'Safety-watchdogs' and those who draft the reports relating to fatal or serious events. Untrammelled Hubris perhaps? A protected species? Or, just feeling safe and secure due to the appalling lack of CASA 'scrutiny' surveillance, operational 'savvy' and disinterest in a few 'cowboys' playing at silly buggers? Or, perhaps there existed a pervasive 'culture' – one based on a certain knowledge that 'operational' surveillance, over-sight, and 'control' had been ceded to the 'operator'. A culture which fooled a disinterested, reluctant oversight agency to wriggle out of any responsibility under the umbrella of AWK and 'specialised operation, conducted under a SMS which 'satisfied' while being completely and permanently parked on a dusty shelf after 'approval'. ATSB fail to mention CASA audit, surveillance or even 'advice' after the issue of the 'certificate'. The knock effect of this 'disregard' for the 'authority' and their happy acceptance of the get out of jail paperwork - they approved; created an atmosphere of complete 'safety' from any form of 'operational restraint', continued oversight, or even operational sanity; being convinced that now; approved (accepted)  they were 'untouchable'.

The ultimate responsibility for the fatal event in Broome rests solely with the CASA; the clearly enunciated warnings were there; writ large and bold. Firearms, drugs, crazy operational approvals, disregard for a DAS edict prohibiting the use of the R44. Long, long list of the inevitable odds on. This is reflected, clearly and demonstrably in the death of two lives, one an innocent, wide eyed young lady; in Broome; despite engineering uncertainty of an aircraft's serviceability. Reckless - just a bit.....

But, for mine the 'kicker' is the take off profile for the R44: take a look – the 'dope-on-the-rope' needs to be able to run; with a rope attached and gear and a large loaded gun strapped on, at 5 knots to keep the chopper performance 'legal' at 10 feet – check the flight manual graph.

ATSB and CASA complicit in arguably the biggest load of 'Bollocks' ever foisted on the public purse. It is the knock-on effect of terminal hubris; and operational approvals issued due to a legal sleight of hand,  manipulating the disinterested Authorities arse covering antics into 'approval' and ATSB willingness to compound that complete failure.

The tale of the old lady airlifted by a private pilot, from a boat at sea, transported back to his house to await uncoordinated, unknown carrier transport to medical care and invoiced as a charter, without any form of 'operational' control, CASA approval, or legal accountability beggars belief. Great to see our much publicised 'safety watch dog' in action; using the blind eye and deaf ear technique so favoured in the third world. Bravo; well done. Surveillance? WTD is that supposed to be?

[Peetwo]

Willow Wilson's widow to sue CASA?? - 

Via the Oz:

Netflix star Chris Wilson’s widow sues CASA and Outback Wrangler Matt Wright’s company Helibrook

By Kristen Shorten:



The widow of Netflix star Chris Wilson – who was killed in a Northern Territory chopper crash – has hired one of the country’s best aviation barristers to sue the company of Outback Wrangler Matt Wright and the Civil Aviation Safety Authority.

Danielle Wilson lost her husband on February 28 last year when the helicopter he was slinging beneath crashed in a remote part of West Arnhem Land during a crocodile egg collecting mission.

Wilson – who starred on reality television shows including Outback Wrangler and Wild Croc Territory – also left behind the couple’s two young sons, Ted and Austin. Pilot Sebastian Robinson suffered severe spinal injuries and is now paraplegic.

The destroyed Robinson R44 Raven II was owned and operated by Wright’s company Helibrook and was operating under a CASA instrument – which allowed Helibrook to sling a person beneath their piston engine powered helicopters for the purpose of crocodile egg collecting – at the time it crashed.

Ms Wilson has since engaged Salerno Law managing partner Cliff Savala, who briefed barrister David Lloyd SC from Sydney’s 12 Wentworth Selborne Chambers, to represent her.



Mr Lloyd also acted for widow Julie Black, who sued CASA – and received a confidential settlement days before the Supreme Court showdown was set to begin – over the death of her pilot husband David, who was killed while firebombing in 2013.

Ms Wilson’s application, prepared by Mr Lloyd, was filed in the New South Wales Registry of the Federal Court of Australia on Tuesday.

The application – which names CASA and Helibrook as the respondents – is seeking damages, interest, costs, interest on costs and “such other order as the court sees fit”.

A spokesperson for Gillis Delaney Lawyers, which represents Wright, this afternoon said the proceeding had been forwarded to Helibrook’s insurer who will be conducting the defence to the claim.

CASA today said it would be “inappropriate to comment on matters before, or expected to be before, the courts”.

Ms Wilson launched the costly litigation just a few months before the strict two-year time limitation, which applies to civil aviation matters, was set to expire.



The case is expected to be assigned to a Federal Court judge by early next year, at which time the respondents will be ordered to file a response to Ms Wilson’s allegations.

The 33-year-old filed her application in Sydney but the matter might be heard in her hometown of Darwin when it comes before the Federal Court for a directions hearing, or case management as it is called in the NT, next year.

The civil action comes less than a fortnight after the Australian Transport Safety Bureau released its 113-page final report into her husband’s fatal accident, which found that the helicopter likely collided with terrain soon after take-off due to fuel exhaustion, but also laid bare a litany of failures and serious safety issues involving CASA and Helibrook.

“The ATSB found that Helibrook’s CASA-approved safety management system was not being used to systematically identify and manage operational hazards,” the findings stated.

“As a result, the risks inherent in conducting human sling operations, such as carriage of the egg collector above a survivable fall height, were not adequately addressed.”



The federal investigation revealed that CASA issued annual authorisations for crocodile egg collectors – which allowed them to sling a person beneath their piston engine powered helicopters – for 15 years without seeing or conducting a single risk assessment.

The ATSB found that CASA delegates had removed safety conditions from crocodile egg collecting authorisations, including a crucial 5m height rule, making it more likely the sling person would be killed if the helicopter’s engine failed.

And in September 2021, CASA granted Helibrook a 40-month exemption to looming new flight rules that stipulated only the safer turbine engine powered helicopters were permitted to be used for human slinging operations.

Just months later, Wilson was dead when Helibrook’s piston engine powered helicopter crashed with the 34-year-old slinging beneath it.

Since Wilson’s death NT Police have charged Wright, former police officer Neil Mellon and pilot Michael Burbidge – who was on the egg collecting mission and discovered the destroyed helicopter – with serious criminal offences related to investigations into the fatal crash.

The three men are due to face a committal hearing in the Darwin Local Court tomorrow.

Plus, via the ABC:

Widow of Outback Wrangler star Chris 'Willow' Wilson sues Matt Wright-owned Helibrook, CASA over fatal crash

By Jack Hislop


Danielle Wilson is suing over the helicopter crash that killed her husband, Chris "Willow" Wilson. (Supplied)

The widow of Outback Wrangler star Chris "Willow" Wilson is suing his co-star Matt Wright's helicopter company and Australia's aviation safety regulator over the chopper crash that killed her husband.

Key points:

• Chris "Willow" Wilson died in a helicopter crash during a crocodile egg-collecting mission in Arnhem Land in February 2022
  
• An ATSB investigation found the likely cause of the crash was fuel exhaustion
  
• Three men, including Matt Wright, are facing a string of charges over the incident
  

On Tuesday, Salerno Law managing partner Cliff Savala filed an application in the Federal Court on behalf of Danielle Wilson, regarding the 2022 crash in remote West Arnhem Land.

The application lists Mr Wright's helicopter company Helibrook and the Civil Aviation Safety Authority (CASA) as respondents.

The ABC understands Ms Wilson is seeking damages, interest, costs, interest on costs and other orders as the court sees fit.

David Lloyd SC, a barrister who specialises in aviation cases, has been briefed as senior counsel on behalf of Ms Wilson.


Chris "Willow" Wilson starred in National Geographic's Outback Wrangler and Netflix's Wild Croc Territory.(Supplied)

Mr Wilson was killed when the Robinson R44 helicopter he was travelling in, which was operated by Helibrook, crashed during a crocodile egg-collecting mission on February 28 last year.

He died at the scene, while pilot Sebastian Robinson was seriously injured.

Mr Wilson was one of the stars of National Geographic TV series Outback Wrangler and Netflix show Wild Croc Territory. Both programs also starred Mr Wright.


Matt Wright is facing criminal charges over the crash.(ABC News: Tiffany Parker)

Last month, the Australian Transport Safety Bureau (ATSB) released its final report into the crash, which found the helicopter had likely crashed due to fuel exhaustion, causing its engine to stop mid-flight.

It also found the chopper had likely not been refuelled at a fuel depot between Darwin and the crocodile egg collection area it had been travelling to, and that Mr Robinson had not identified the reducing fuel state.

Regarding Helibrook, the ATSB found the company had not been using its safety management system to identify and manage operational hazards at the time of the incident.

The ATSB said that had increased the risk of the helicopter experiencing a technical failure or malfunction, though there was no evidence it had contributed to the crash that killed Mr Wilson.

The report also found it was likely Helibrook had overrun the helicopter's maintenance, inspection and overhaul periods.

Findings were also made by the ATSB against CASA, around the use of slings on helicopters during crocodile egg-collecting missions.

It found CASA, in authorising pilots to sling a person beneath a helicopter, did not have "an effective process" for ensuring that authorisation would not adversely affect safety.


The helicopter crashed shortly after take-off in remote West Arnhem Land.(Supplied: Careflight)
Three men, including Mr Wright, are facing a string of offences over the fatal helicopter crash.

The charges against Mr Wright include attempting to pervert the course of justice, fabricating evidence and two counts of unlawful entry.

He was not aboard the helicopter when it crashed and has strenuously denied the allegations.

The Darwin Local Court will on Thursday hear a preliminary examination application regarding the criminal case against Mr Wright.

MTF...P2

[P7_TOM]

Rien ne va plus.. Yup; in Spades.....

Funny old world though, 'in-it'. The 'charges' (yet to be proven) against the 'Croc – botherer' fellah took about 20 minutes (by the judicial clock) to formulate, in court time about (by the judicial clock) about 24 hours to be formalised and actioned. Rapid stuff ; but the amazing part is the 'CASA clock' had been running for years and years but they could not uncover the gross breaches in operational sanity and compliance, long before someone got injured or worse; yet it is not rocket science.

Any one of the 'known' potential fatal events could and should have been prevented by timely intervention and ongoing surveillance. As kids we never went anywhere near the Vicars orchard unless we knew where the local Bobby was. Great deterrent.

So, the alleged crimes which could have been prevented fall to the 'Croc – Idiot' to defend; fair enough some would say. But what of the crew which could, possibly, (probably) have prevented such 'derring-do', hubris and; why CASA exhibited such laissez-faire toward this 'high risk' operation?: .

But the low spot (the pits) of all this sorry saga is that CASA and its minions and the minister will merrily trot along, without a care in the world; maybe even go for a 'free-be' chopper ride – this before they may fire some insignificant, unfortunate saddled with a 'non-disclosure' notice, the one who – probably -  the only one, who kept ringing the alarum bell. Nope, non of this signifies; the party continues and yet, despite the mountain of evidence; the media just keep on letting 'em get away with it:-(and listening to the Popinjay's spun bullshit)  Remarkable...........but

For clarity -

[Peetwo]

Croc-o-shite update: 19/12/23

Via the Oz:

Chris Wilson’s widow claims CASA and Helibrook breached ‘duty of care’ before fatal chopper crash

By KRISTIN SHORTEN



The widow of Netflix star Chris Wilson claims the Civil Aviation Safety Authority and Outback Wrangler Matt Wright’s company Helibrook were both negligent and breached their duty of care in allowing her husband to be slung beneath a piston engine-powered chopper to collect crocodile eggs the day he was killed.

Danielle Wilson’s statement of claim, filed in the Federal Court and obtained by The Australian, alleges her husband’s death in a Northern Territory chopper crash last year was caused by “wrongful acts or omissions” of respondents CASA and Helibrook.

Ms Wilson lost her husband and the father of her two children on February 28, 2022, when the helicopter he was slinging beneath crashed in a remote part of West Arnhem Land during a crocodile egg-collecting mission.

The 34-year-old, who was suspended below the helicopter in a harness attached to a 30m line, was released as the chopper crashed soon after takeoff from a clearing near the King River.

Pilot Sebastian Robinson was critically injured in the crash and is now paraplegic.

The destroyed Robinson R44 Raven II, registered VH-IDW, was owned and operated by Wright’s company Helibrook, and contracted to Wild Harvest NT.



Following her husband’s death, Ms Wilson engaged Salerno Law managing partner Cliff Savala, who briefed aviation barrister David Lloyd SC and his junior counsel Matthew Kalyk from 12 Wentworth Selborne, to sue Helibrook and CASA.

The young widow launched the litigation just a fortnight after the Australian Transport Safety Bureau released its final report into the fatal crash.

The ATSB found that the helicopter likely collided with terrain soon after takeoff due to fuel exhaustion, but also identified serious safety issues involving CASA and Helibrook.

The chopper was being operated under a CASA authorisation – which allowed Helibrook to sling a person beneath their piston engine powered helicopters for the purpose of crocodile egg collecting – at the time it crashed.

Crocodile egg collecting operators had received essentially the same approval instrument renewal each year since 2007 without CASA ever conducting or citing a risk assessment for the activity.

The conditions of the instrument were continually relaxed until 2017 when CASA delegates removed crucial safety rules, including height and speed limits for carrying a sling person, from the approvals altogether.

This significantly increased the activity’s overall risk because falls from greater than 5m are usually unsurvivable.



CASA issued Helibrook’s first approval instrument to conduct Human External Cargo (HEC) operations for crocodile egg collection in 2016 and renewed it each year.

Helibrook’s most recent authorisation, issued in September 2021, gave the company a 40-month exemption to looming new flight rules – introduced in December 2021 – that stipulated only the safer turbine engine powered helicopters were permitted to be used for the activity.

Months later Wilson was dead, after Helibrook’s piston engine powered helicopter crashed with the young father suspended beneath it.

“Mr Wilson died from a fall, from a height greater than 5m, following his release from the line while operating as an HEC,” court documents state.

“VH-IDW hit a tree, experienced engine failure, ran out of fuel or otherwise crashed.

“The crash of the helicopter and Mr Wilson’s death was caused by the wrongful acts or omissions of the respondents … or alternatively the wrongful acts or omissions materially contributed to Mr Wilson’s death.”



Ms Wilson claims that CASA breached its duty of care by approving slinging operations, approving Helibrook’s performance of slinging operations, approving Helibrook’s safety management system and granting an exemption to Helibrook from the new flight rules implemented in December 2021.

She further claims CASA did so “without appropriate conditions, without conducting a proper and appropriate risk assessment and without conducting ongoing monitoring, assessment and/or verification of participants conducting the activity and their practices (in particular Helibrook)”.

Court documents allege Helibrook breached its duty of care by “failing to take the reasonable precautions against the risk of harm” and undertaking “no risk assessment of the slinging operation at all”.

It is also alleged that Helibrook failed to engage suitable pilots, properly train pilots and other personnel in relation to slinging operations and failed to ensure that the pilots briefed the crew on the emergency procedures in accordance with its own policy.

“(Helibrook) failed to ensure that VH-IDW was adequately maintained and its flying hours recorded, failed to have in place an appropriate safety culture and appropriate systems, practices and procedures, permitted VH-IDW to be flown in a manner that compromised the pilots’ ability to ensure there was adequate fuel for a given operation and permitted VH-IDW to be flown outside its operating limits,” the claim states.

The application states that Mr Robinson, for whom it says “Helibrook is vicariously liable as employer or equivalent”, also failed to undertake a risk assessment of the slinging operation and “owed Mr Wilson a duty of care as pilot of the aircraft while Mr Wilson was vulnerable as an HEC”.



The application posits that helicopter fuel and power management becomes increasingly complex when HEC is involved, slinging can cause the pilot’s attention to be diverted from the cockpit dashboard to what is happening below and that there is a heightened risk of engine failure and fuel exhaustion when conducting HEC operations.

The single mum is seeking damages, interest, costs, interest on costs and “such other order as the court sees fit”.

“As a result of this conduct, the applicant suffered nervous shock or psychiatric harm and loss of maintenance and financial support of Mr Wilson during the course of his lifetime,” the claim states.

A spokesperson for Gillis Delaney Lawyers, which represents Wright, said QBE – represented by Carter Newell Lawyers – “will be conducting the defence to the claim”.

“And we expect that the contractor pilot and his company will be joined in the proceedings,” he said.

CASA, which is being represented by Minter Ellison, declined to comment on matters before the courts.

A case management hearing will take place before Justice Elizabeth Raper in February.

MTF...P2 

[Peetwo]

Bollocks Broome R44 crash and ICAO SSP audit??

Still catching up on some Oz articles that featured the many aberrations of the Troy Thomas aviation activities and operations in the NW Kimberley.

Courtesy the Oz:

Complaint videos sent to CASA show pilot Troy Thomas illegally landing on Cockatoo Island



Videos of unsafe flying – sent to the Civil Aviation Safety Authority with written complaints about dangerous incidents in the Kimberley – show the helicopters involved were not only owned by West Australian tourism stalwart Troy Thomas, but on at least one occasion he was also the pilot.

The Australian revealed last month CASA had investigated and dismissed a spate of dangerous flying allegations involving helicopters owned by Thomas and his companies a year before the Broome crash that killed him and 12-year-old Amber Millar.

Documents obtained by The Australian under Freedom of Information laws revealed CASA in 2018 received five written complaints, accompanied by photo and video evidence, of “unsafe behaviour” involving aircraft badged Horizontal Falls Seaplane Adventures, which Thomas founded and owned at the time.

When The Australian last month revealed CASA dismissed the complaints in 2019, a year before his fatal crash, the regulator said it “refutes the allegations”.

“Each of the 2018 incidents was investigated and acted on by CASA and not one of them involved Mr Thomas,” a spokesperson said.

However, The Australian has now obtained video evidence – through a further Freedom of Information application – that appears to show Thomas as the pilot in at least one of the incidents.

The 2018 reports to CASA sparked a noncompliance investigation into Helibrook, the aviation business of Outback Wrangler star Matt Wright, because Thomas’s choppers were operating under his Air Operator’s Certificate.

Helibrook’s chief pilot from 2018, Fraser Kenworthy, yesterday told The Australian that he recalls the Cockatoo Island incident.

“I remember the day,” he said. “But you see the thing is, I was the chief pilot for the commercial operations but he (Thomas) wasn‘t a commercial pilot so he flew the same aircraft that we were using commercially but it had nothing to do with my operation.

“I never had to answer to anything that he was doing because his was a private operation … so ultimately it had nothing to do with me.”



Last month CASA denied any knowledge of Thomas’s involvement in the incidents.

“CASA does not normally investigate the owners of aircraft involved in accidents or incidents – as many are owned under complex financial and shareholding arrangements,” the regulator said in a lengthy statement published on its website.

“CASA was aware of only one previous incident that Mr Thomas was involved in prior to his fatal accident. That incident resulted in enforcement action being taken against Mr Thomas.”

In one of the videos – filmed on July 2, 2018 – a pilot who appears to be Thomas lands his Robinson R44 Clipper II, registered VH-ZGY, on Cockatoo Island in Western Australia. The chopper’s passenger doors open, someone approaches, something yellow is put on the back seat and the pilot flies off.

At the time, a Cockatoo Island resident complained to CASA that the chopper made “an unauthorised landing on our property” and that it had happened multiple times “by the same operator in the past few weeks”.



The other three videos supplied to CASA show helicopters badged Horizontal Falls Seaplane Adventures flying dangerously low and through narrow gorges at Horizontal Falls, about 270km northeast of Broome.

Footage filmed from another aircraft shows a helicopter – possibly VH-ZGY – flying dangerously low towards a 20m-wide gorge in the McLarty Range.

In an incident filmed from a boat at Talbot Bay, a helicopter flies back and forth through a narrow channel in the Horizontal Falls. “That’s close,” someone says as the chopper flies low through a narrow 10-metre wide cliff passage.

A person on board the boat below tells a companion to “film the chopper doing that stuff”.

“It’s really very illegal,” a man is heard saying. “It’s very, very illegal.”



A separate video, filmed from another boat, captures the blue-looking helicopter flying low into a narrow gorge.

“You’re kidding,” someone on the boat says. “Even I know you can’t do that.”

In 2019, Thomas crashed the chopper he had landed on Cockatoo Island – VH-ZGY – off the top of his vessel High Calibre at Raft Point, north of Broome.

The incident, in which passengers were seriously injured and the aircraft was lost, was not reported to authorities.

CASA investigated a separate 2017 incident in which one of Thomas’s helicopters, VH-SCM, crashed off the top of a boat and into the water at Talbot Bay but never inspected the destroyed helicopter.

The written-off choppers belonged to Thomas’s company, Avanova Pty Ltd.

He operated five helicopters for private, business and commercial purposes.



The Australian Transport Safety Bureau’s final report into Thomas’s fatal Broome crash stated the 40-year-old had demonstrated “a high-risk appetite”, a history of noncompliance with aviation laws, was unlicensed to fly the destroyed Robinson R44 and knew there was a serious issue with it before taking off on that final fatal flight.

Last month, Amber’s parents, Fiona and Clint Benbow, said CASA had “blood on its hands” over their daughter’s death and called for an inquiry into the federal regulator over its perceived failure to act on complaints about Thomas.

They have also begged WA Coroner Ros Fogliani for a coronial inquest.

WA Premier Roger Cook recently said an inquest “looks like being the only vehicle that we can now rely upon to do that level of investigation”.

“There‘s an absolute dearth of people on the ground and commitment by CASA to investigate and follow up these things or to maintain a regulatory oversight of tourism and helicopter aviation generally,” he said.

And 2 weeks ago:

Injured chopper passenger Chelsea Cortese sues dead pilot Troy Thomas’ company Avanova



A Western Australian woman injured in a serious chopper crash with pilot Troy Thomas, less than a year before the fatal incident that killed him and a 12-year-old girl, is suing the late tourism stalwart’s aviation company.

Documents obtained from the Perth District Court reveal that passenger Chelsea Cortese is suing Thomas’s company Avanova Pty Ltd – which owned and operated his helicopter fleet – for damages over injuries she suffered in an unreported 2019 helicopter crash.

In July 2020, Thomas and Perth schoolgirl Amber Millar were killed when his Robinson R44 – registered VH-NBY – crashed immediately after takeoff from an industrial site in Broome.

But less than a year earlier, Thomas was the pilot in another serious helicopter crash in the Kimberley which injured everyone on board and destroyed the aircraft.

In July 2019, Thomas crashed his Robinson R44 – registered VH-ZGY – off the top of his catamaran, High Calibre, which was moored at Raft Point off the coast of Broome.



On the morning of July 12, Thomas, his operations manager Bryce McGlashan and Ms Cortese had boarded the helicopter to return to Thomas’s Horizontal Falls Seaplane Adventures pontoon.

Mr McGlashan, also a pilot, was sitting in the front passenger seat while Ms Cortese sat behind him.

The weather was fine and the water in the bay was calm but as soon as Thomas tried to takeoff, the helicopter yawed left, tipped forwards and rolled to the right.

The main rotor blades struck the starboard side of the vessel. The helicopter then hit the water and sank.

Mr McGlashan sustained serious physical injuries and Thomas, who was unlicensed at the time, suffered severe bruising and a sore neck.

Ms Cortese, who was aged 20 at the time, suffered severe injuries after almost drowning.

In its final report into the fatal Broome crash, the Australian Transport Safety Bureau said no-one reported this incident involving VH-ZGY to authorities.

The ATSB only discovered the crash, which was by law “immediately reportable”, during its three-year investigation into the Broome fatalities.



Ms Cortese’s statement of claim states that VH-ZGY crashed because it was still tethered to High Calibre when Thomas tried to take off from the helipad.

“As the helicopter began to take off, there was a holding strap still attached on the underside of the helicopter towards the front, which was pulling the helicopter down, when Troy Thomas manoeuvred the controls of the helicopter to the right, which resulted in the helicopter tilting to the right, and slicing the right hand side of High Calibre, shattering the glass windows, before nose diving into the water,” it says.

“The defendant was negligent in attempting to take off and climb the helicopter while it was still strapped to High Calibre causing a loss of control and the defendant failed to perform adequate pre-flight checks to ensure that the helicopter was not strapped to High Calibre before taking off and failed to exercise sufficient care and skill in the operation of the helicopter to prevent the accident.”



The 24-year-old claims she has since suffered from – and required extensive medical treatment for – severe injuries as a result of the accident.

“As a result of the accident the Plaintiff has experienced pain and suffering and a loss of enjoyment of life,” her lawyer Maureen O’Connell wrote.

“The Plaintiff has been incapacitated and has required and will require in the future the provision of services.

“The Plaintiff has required time off from her employment as a result of the injuries sustained in the accident and has sustained past economic loss and a loss of superannuation and will do so in the future.”

Ms Cortese is suing Avanova for damages, interest and costs.

In court documents Ms O’Connell claims that Avanova owed Ms Cortese a duty of care “to ensure she did not sustain injuries while a passenger in aircraft operated by the company” and that it was vicariously liable for any breach by people employed by or working for it including Thomas.

The Australian’s application to the Perth District Court for a copy of the defence pleadings was refused.

Ms Cortese’s claim against Avanova is expected to proceed to trial early next year.

Sophie Thomas, who was appointed director of Avanova weeks after her husband’s death, declined to comment.

Refer page 48 of AO-2020-033 Final Report:

It was reported to the ATSB that 2 people required transfer to another helicopter (VH-NBY) located nearby on-shore, to return to Broome. A witness stated that VH-ZGY had been used twice already that day and had landed to load a third passenger without shutting down. Simultaneously, friends and family of the vessel’s owner were due to arrive at Raft Point via seaplane to holiday aboard High Calibre. It was reported that the transfer to VH-NBY in VH-ZGY needed to be completed in time for the owner to get back to High Calibre and meet their guests.

The owner of the helicopter was piloting the helicopter and sat front right. One passenger sat front left, and the second passenger sat rear right. It was reported that upon take off the helicopter yawed left and then tipped forwards and rolled to the right. The main rotor blades contacted the starboard side of the vessel (Figure 32). The helicopter then collided with water and sank...


Source: Western Australia Police Force annotated by ATSB

...The front left occupant had serious injury, the owner sat front right, had severe bruising, and the rear right passenger had minor injuries. The helicopter was destroyed. The Civil Aviation Safety Authority confirmed the loss of VH-ZGY with an insurance agent, and the helicopter was not recovered. High Calibre had significant damage and the hull was penetrated above the water line. High Calibre was repaired in a remote location 11 days later...

...Under section 18 of the Transport Safety Investigation Act 2003 a responsible person with knowledge of an immediately reportable matter must report it. The loss of VH-ZGY was not reported to the ATSB.

Hmm...I wonder when CASA 'confirmed the loss of VH-ZGY'...

Next and I believe directly related with all the aberrations of both the ATSB Croc-o-shite and Broome cover-up reports, I note the following throwaway paragraphs imbedded in the latest Su_Spence bollocks briefing:

Also this year, it was our turn to be inspected by the International Civil Aviation Organization as it assessed Australia’s state safety programs and conducted a focused audit.

It was a good reminder that audits, rather than something to be feared, provide useful insights into what we do well and where improvements need to be made.

 
ICAO audit...who knew? Digging around I did manage to find the following statement from the 'Civil Aviation Safety Authority Annual Report 2022-23':

Performance criteria: CASA maintains the Effective Implementation (El) score determined by ICAO Universal Safety Oversight Audit Program (USOAP)

Target - Maintain or improve EI score

Status - ACHIEVED

Australia’s EI score was 94.89% (valid to 30 August 2023), which is unchanged from last year and reflects the outcome of the International Civil Aviation Organization (ICAO) validation mission undertaken in 2017. The EI score is a State score based on the performance of all 9 Australian State Safety Program agencies.

Australia is scheduled to undergo an ICAO State Safety Programme Implementation Assessment (SSPIA) and Focused Audit under the Universal Safety Oversight Audit Programme Continuous Monitoring Approach (USOAP), from 30 August to 19 September 2023.

BRB OBS: "..I reckon that reads like - ‘trying to turn a negative into a positive’. Being a potential international embarrassment for Australia, a SSP audit will always result in significant reaction to criticism. That may explain lots of oddities at present - interesting days. Popinjay’s lack of independence is still a major risk for the SSP..."

Very much a live 'major risk' I would say: Ref:  Popinjay leaks Skerrit Ghost review; & CASA author ATSB corporate plan?

1.3 Accident and incident investigation

The State has established an independent accident and incident investigation process, the sole objective of which is the prevention of accidents and incidents, and not the apportioning of blame or liability. Such investigations are in support of the management of safety in the State. In the operation of the SSP, the State maintains the independence of the accident and incident investigation organization from other State aviation organizations.

Reference ICAO Annex 19 ATTACHMENT A

Much..much MTF...P2

[Peetwo]

Croco-shite cover-up: Su_Spence surveillance and Board bias??

Remember this?

Human external cargo rotorcraft load combination decision

In August 2013, a CASA project was initiated to consider existing HEC regulations and propose amendments to Civil Aviation Order (CAO) 29.6, which only applied to non-human sling operations. The project identified that permissions being issued by CASA regional offices were not issued on the basis of a risk assessment or reflective of international standards. Specifically, in the US, United Kingdom and Canada, HEC was not permitted with piston engine rotorcraft and, CASA had assessed that the use of piston engine helicopters increased the risks to HEC compared with turbine engine rotorcraft. Additionally, in 2013, helicopter operators involved in the powerline industry had approached CASA for HEC approval using turbine engine rotorcraft, consistent with international requirements.

As a result of the project, in October 2013, the then CASA Director of Aviation Safety (DAS) signed an internal minute that recommended CASA restrict HEC operations to the following requirements:

• single engine turbine powered rotorcraft with a usage monitoring system
  
• out of ground effect hover performance with a performance buffer
  
• restrictions on who could be carried
  
• an attachment means certified for the carriage of humans.
  

The minute also recommended that the proposed standard be communicated to CASA field officers for consideration in all authorisation/permission approvals, while the proposed amendment to CAO 29.6 to reflect the policy was being drafted.

As a component of the project, a CASA risk workshop on crocodile egg collection using HEC was held on 20 November 2013. While no minutes were recorded from the meeting, a draft risk management plan (RMP) provided to the ATSB formed the basis of the discussions.

Followed by the now infamous RMP (pg 71), which was pretty much repeatedly ignored by overseeing CASA delegates for the next decade...  :

Risk management plan

The stated purpose of the RMP was:

to examine the risk indicators in HEC operations in a piston engine rotorcraft in an Australian operational context of crocodile egg harvesting.

The RMP was drafted by a senior standards officer with significant helicopter and HEC expertise using a CASA general aviation operations template. The scope included that the assessment:

…considers isolated factors specific to piston engine rotorcraft, single engine turbine rotorcraft and multi-engine turbine rotorcraft. Risks relevant to the task of HEC beneath any rotorcraft are examined for context and amplification. A limitation to scope is that the cumulative effect of the individual risks should they be realised in combination is not considered. It would be prudent to conduct analysis of this eventuality should the risk assessment be furthered.

The assumptions listed in the RMP were:

• Permitted operators must have a proven safety and compliance record underpinned by a robust Safety Management System that could be leveraged for continued operation with strict regulatory oversight.
• CASA will exercise additional oversight of approved operators should an approval be granted that is strictly limited in scope and will result in removal of the operators [sic] approval should any non‑compliance be identified.
• The risk exposed by utilizing an external load assembly not approved for HEC provides a residual risk rating that is acceptable for a finite period of six months.

The overall operational risk of the activity was assessed with an initial risk rating of high (7), which ‘needs senior management attention’, and the residual risk (with controls in place) of medium (5), requiring ‘management responsibility’.

  
FFWD 2021 (pg 75 of FR):

Helibrook’s 2021 instrument

The 2020 instruments were valid until 31 December 2021. On 2 September 2021, the Helibrook safety manager emailed CASA’s Regulatory Services requesting a renewal of the instrument with the 2020 instrument attached to the email. After payment, the task was assigned to the delegate on 9 September 2021, who recalled that it was relatively urgent. The delegate reported being unaware of the history of the authorisation, but was aware of the general risk of the operation and that it had been assessed by multiple sections within CASA.

The delegate reviewed the file relating to the most recent instruments and emailed the previous approver asking whether there were any concerns regarding reissue of the instrument to Helibrook. The previous approver advised that:

• the STC for the hooks had been issued on 30 July 2021
  
• there had been no changes to Helibrook’s equipment or procedures that they were aware of
  
• CASR Part 138 was not yet in force
  
• considering the above, they saw no reason why a new instrument should not be issued.
  

They also commented that they did not believe there was a compelling statistical argument to justify the higher cost of a turbine engine helicopter that would be required under Part 138.

The delegate then signed the instrument on 9 September 2021 with an expiry date of 31 December 2024. There was no change to the conditions from the previous year’s instrument. The references to the now redundant EO were not removed. Condition 23 stated that when the STC is approved, ‘all aircraft previously certified to the [engineering order] EO will be shown to be compliant with and certified to the STC within 14 days of the STC being approved, after which time aircraft certified only to the EO may no longer undertake this work’. Helibrook did not update the hook installation on VH-IDW to the STC. The delegate reported that they were unsure about whether the hooks had been certified. The delegate also reported being unaware of the implications of the impending Part 138 requirements when they issued the instrument for a 3-year period.

Passing coincidence that 3 months before, according to the CASA Gifts and Benefits register, this happened:

23 June: Crocodile Farms NT gifted a briefing and helicopter flight demonstrating crocodile egg collection operation to Tony Mathews, Pip Spence, Michael Bridge and Elizabeth Hallett in Northern Territory. Estimated value is not quantified.

From the CASA website it states:

The CASA Board consists of the Chair (of the Board of Directors), 5 non-executive directors and the CEO and DAS.

The Board decides the objectives, strategies and policies that we will follow. They also ensure we perform our functions properly, efficiently and effectively. Besides their prescribed duties under our Act, the Board also receives specific direction through our minister’s Statement of Expectations.

Basically the Board oversees the proper governance of CASA, no mention about surveillance or flight operation inspections??

Next reference:

23 May 2023 All documents and correspondence related to the 23 June 2021 Crocodile Farms NT gift of a briefing and helicopter flight.

Freedom of Information (FOI) - 23 June 2021 Helicopter Flight

Join the dot extracts:

Fairly easy to fill in the blanks.

OBS: 

• Su_Spence was barely a month into her tenure as DAS/CEO
  
• It would appear that neither the Scot Git or Craig Martin (Reg Oversight Exec Manager at the time), provided any background checks or safety risk assessments to the Board or the new DAS prior to the meeting with Crocodile Farms NT and the Helibrook CEO/CP.
  
• The meeting was always about the incoming flight ops regs that would preclude Helibrook from conducting HEC croc egg collection in R44 helicopters.
  

   

Note the ignorance and naivety of PS, her only concern was whether she should have offered costs for the flight conducted by a repeat offender of non-compliances and illegal activity in contravention of the CAA and regulations.



Note that the section C declaration is not signed??



The former Chair Tony Mathews poor judgement to allow himself, Bridges and SuSpence to participate in the HEC OBS/surveillance flight probably reflected a zero care factor, being that he was only 6 months out from the end of his tenure.

Now FFWD to the 9 September 2021 re-issued instrument above and the subsequent fatal accident on 28 February 2022??

Wonder why the Board's contributory factor (hole) to the Croco-shite Swiss Cheese was not mentioned in the bollocks Popinjay systemic investigation final report? Where's the referral for a SSP safety case into the duplicity and serious deficiencies in CASA oversight and surveillance of AOC holders?

MTF...P2

[Wombat]

Let me get this straight; October 2013 - DAS says nix piston engined sling work.

November 2013 - As a component of the project, a CASA risk workshop on crocodile egg collection using HEC was held on 20 November 2013. While no minutes were recorded from the meeting, a draft risk management plan (RMP) provided to the ATSB formed the basis of the discussions.

September 2021 - CASA is still issuing exemptions for piston engine sling work.

Eight years?

What else is languishing in CASAs cellars???? Since when did a meeting like this have no minutes?

[Sandy Reith]

Wombat …” What else is languishing in CASAs cellars???? Since when did a meeting like this have no minutes?”

Of course it’s the never ending story, for one very obvious reason. The great Australian answer to all sorts of governing matters, find an umpire (if only it was as simple as a game of footy); create an independent commissioner, a corporation like CASA, an Ombudsman, an IBAC or ICAC to name but a few types or lets have a lengthy and expensive inquiry to recommend such a body.

It’s a beautiful thing because we Australians love to denigrate our politicians which even leads them to believe that they are not up to the job, or won’t need to take a full measure of responsibility. Thus the great symmetry, we let them off the hook of accountability and blame for all wrongs is handily deflected away from our elected Members of Parliament, and ourselves for electing them. . .

CASA must be disbanded and its functions handled within a Department of Government with a responsible Minister at head. We should pay our MPs at least double and no Public Servant should receive more than a Minister.

[Peetwo]

Bouttell joins the Su_Spence deckchair shuffle?? -

Prior to Xmas the following was the, bizarre and IMO seemingly dysfunctional, published CASA Org Chart:



Huh...Joe Rule the acting National Operations and Standards Executive Manager?? -

Rumour is there are some more serious deckchair shuffles, plus some questionable additions to the Pup Spence regime, yet to come.

Which brings me to today's Oz Flying article:

Matt Bouttell to leave RAAus

15 January 2024



Recreational Aviation Australia (RAAus) is searching for a new CEO after Matt Bouttell announced last month he would be leaving for another role in aviation.

It is expected Bouttell will leave in mid February for an Executive Manager position with the Civil Aviation Safety Authority.

Bouttell said he decided to move on after seeing out his three-year contract with RAAus.

"Leading the RAAus team as CEO has been an incredible privilege," Bouttell said in a member communique. "I cannot emphasise enough how hard this team of 20 staff work to make your interactions with us positive, to enable new privileges like Group G, to assist you in being safe aviators, and to support our flight training schools across the country.

"We take immense pride in all that we do at RAAus, which has grown from humble beginnings into a professional and modern organisation that exists to enable our members to take to the skies."

Bouttell took over as CEO three years ago after the departure of Michael Linke. He was immediately challenged by the impact of the COVID-19 pandemic.

"I’m really proud of what we’ve achieved in the past three years," he said. "Whilst coming out of COVID was a challenge with our staff working from home through lockdowns, we continued to provide uninterrupted service to members, managed to implement Part 149, put systems in place to maintain assurance, finally got Group G over the line, and above all, strived to enable our members to operate with as little fuss as possible."

This will be Bouttell's second stint at CASA, having previously worked at the regulator in an industry relations role.

RAAus is temporarily under the management of Corporate Services Executive Maxine Milera, and an announcement on a replacement CEO is expected in the coming weeks.

Anyone notice how if you happen to snag a position on the DAS personally selected ASAP, that it is only a matter of time before you end up in some plum position in CASA??

That aside I note that, some weeks ago on LinkedIn, Boutell leaked the position he would be taking up at Fort Fumble HQ...

Matthew Bouttell

Chief Executive Officer at Recreational Aviation Australia
3w •

It's with mixed emotions to announce that I'll be departing Recreational Aviation Australia as CEO in February next year. I've thoroughly enjoyed my three years at RAAus, leading a very special team of committed experts as they deliver for our members. I've also been very fortunate to report to a Board that is highly committed to governance and member interests. I'll be watching with keen interest as RAAus goes from strength to strength!

The Board will announce their plans for my replacement in due course.

In February I'll be commencing a new role as Executive Manager Regulatory Oversight Division with the Civil Aviation Safety Authority. I'm really looking forward to heading back to CASA and working to further aviation safety and supporting industry to do that.

Have a Merry Christmas everyone and a safe 2024!

Hmm...no comment (yet) -

MTF...P2

[Earl Lank]

No doubt the result of the usual exhaustive, world-wide executive recruitment process involving a strong field of candidates subjected to stringent tests and interviews against objective selection criteria by an objective selection panel.

[Sandy Reith]

Earl you have not understood how the Commonwealth wheels rotate. Far better to employ those who understand the Canberra ethos. It’s all so smooth, no bumps or undesirable outcomes. For example someone having to take responsibility for a less than perfect outcome, such as some difficult GA person who won’t take a hint and lie down after a minor administrative adjustment. People need to understand the way things are run for the betterment of all Canberrans. There’s so many intertwined networks, including highly paid consulting work reserved for former PS staff. Plenty of inquiry work to fall back upon when looking busy is wearing a bit thin. Inter Departmental exchange workshops in QLD, Winter is a good time to leave Canberra, these are perennial standbys.

[Peetwo]

The deckchair shuffle continues?? - 

Via the LMH:

RAAA CEO returns to CASA

17 January 2024



Regional Aviation Association of Australia (RAAA) CEO Steve Campbell has left the association to take up a managerial role with CASA.
Campbell becomes the second association CEO to return to the regulator in recent months after RAAus CEO Matt Bouttell also accepted an Executive Manager position.

Campbell will take on National Operations and Standards with Bouttell appointed to head the Regulatory Oversight team.

Campbell spent three years as RAAA CEO and during that time was instrumental in developing policy regarding importing engineers and the Federal Government's aviation green paper. He also negotiated with AMDA Foundation to support a series of RAAA roadshows around the country.

Previously, Campbell served as aviation advisor to former Minister for Infrastructure and Transport Michael McCormack and had careers in GA, regional airlines and with Cathay Pacific, peaking as check-and-training captain on B777s.

Campbell is expected to take up his new role at CASA in February.

From the man who headed up the taskforce for Part 61, 141/142 and brown nosed his way through two Transport Minister's and St Commode's office - God Help the Industry! (Because PS and the CASA Board never will)   

MTF...P2 

[Peetwo]

Dots-n-dashes into the VFR into IMC GRASP for ICAO (GASP/RASP/NASP) SSP credibility??

Nearly missed this, courtesy Su_Spence HQ:

Type - Media release
Date - 11 January 2024

The Civil Aviation Safety Authority (CASA) is reminding pilots of the importance of pre-flight planning, interpreting weather forecasts and monitoring for deteriorating weather.



This reminder follows the release of a report from the Australian Transport Safety Bureau (ATSB) today into a tragic accident in which a helicopter entered cloud and collided with terrain over Mount Disappointment on 31 March 2022 while attempting to conduct a U-turn out of poor weather.

CASA Chief Executive Officer and Director of Aviation Safety Pip Spence said that it was important to look at what went wrong, and what could be learnt to prevent similar accidents occurring in the future.

'All pilots will encounter bad weather at some stage in their flying careers,' Ms Spence says.

'Thorough pre-flight planning and understanding of weather forecasts and meteorological conditions help pilots determine if the weather is acceptable for a visual flight rules flight.

'However, it is also important that pilots are able to recognise deterioration in the weather to make an early and safe decision to turn back while in clear conditions – this action will avoid flying into conditions for which they are not trained and equipped.

'We encourage pilots to refresh their skills using the tools and resources available on CASA's pilot safety hub.'

Several new 'explainer' videos were released late last year to help pilots understand weather forecasts and improve their weather-related decision-making.

New resources to help pilots with their pre-flight planning, including resources specifically aimed at helicopter pilots, will be released over the coming months.

The ATSB report also recommends that CASA take safety action to further address the risk to commercial helicopter operations from inadvertent IMC events.

CASA is considering this recommendation in the context of this and other recent ATSB reports involving inadvertent instrument meteorological condition events.

Pre-flight planning is the current focus of CASA's pilot safety education campaign (Your safety is in your hands) and will run from January to March 2024.

The previous quarter saw a focus on the important topic of weather and forecasting. Safety and occurrence data from the ATSB is used to inform the campaign topics and safety messages.

It would seem that Su_Spence & CO are stumped for answers but how can this be so when we are supposed to have a fully functioning SSP that is compliant with the latest NASP: https://www.atsb.gov.au/safety-issues/AO-2022-016-SI-05 &  Popinjay v Su_Spence; closing safety loops?? - Let's do the timewarp again!

The Australian National Aviation Safety Plan 2021-2023, to which the ATSB and CASA were contributing agencies, stated Australia’s acceptable level of safety performance included:

No accidents involving commercial air transport that result in serious injuries or fatalities, no serious injuries or fatalities to third parties as a result of aviation activities and improving safety performance across all sectors.

Therefore, any risk assessment of a fatal commercial air transport accident by CASA should be consistent with Australia’s stated acceptable level of safety performance. To progress towards this level of safety, CASA need to capture lessons learned from fatal accidents in Australia in the Australian aviation standards.

For the benefit of the NFI Su_Spence here is the Ferryman analysis:

Of attributable Bollocks and:-

Squibs purporting to be 'Bombshells'.

I have cribbed the quoted 'text' from a News.com article, by Liam Beatty. We can readily forgive the journalistic naivete as the thick coat of gloss and ATSB mumbo jumbo would mislead many of those who have a nodding acquaintance with air operations - even at the professional level. There, compliance is paramount with 'grey-ish' letter law; the first question asked of any operation "is it legal"?  Is it "safe"? (whatever that may mean) is rarely asked of a 'routine' matter. The precursor is a notion that if it is 'legal' then, it must be 'safe'; or, at least able to be 'seen' to be during the 'investigation' then all is well. Enter ATSB Bollocks #1.

ATSB Bollocks #2 - "An investigation into a horror helicopter crash which killed five people in Victoria has concluded the flight should have been cancelled because of weather conditions."

Well; this was a 'commercial' operation, the paying passengers would have an expectation, even if pre warned, to get where they want to go. Unless the 'operations' staff (meet and great) can declare, categorically, that the weather conditions totally preclude departure - even then eyebrows will be raised. Out will come the I-phones calls will be made and weather conditions checked. Best result, seasoned travellers will wait' or reschedule, they understand; the not so much crew will haul off in a huff, find another operator and have a 50/50 chance of securing a ride. Such is human nature. However, as most 'commercial' VFR operations will do; they will launch and compare the 'actual' conditions to the 'forecast' conditions; maybe they squeak through; maybe they don't; such is the game of VFR operations, and much depends on many complex factors. But, on the day's forecast, provided the passengers were happy to accept that the weather was forecast as 'sketchy' and the possibility of a return to base was on the cards; then it would be acceptable to go and see what conditions really were. That 'risk' element quite operationally sensible and commercially acceptable.

ATSB Bollocks #3 - "A new report by the Australian Transport Safety Bureau released this week found Mr Neal and the second pilot were not qualified to fly in rough weather and held concerns about the conditions before the trip."

Tricky one this; not  concerned enough to exercise 'command prerogative though. 'Inadvertent' or 'deliberate' entry into cloud? That is the question. Clouds ain't invisible; nor is good old terra firma; particularly of the mountainous kind. Take a look through the cockpit window; is there a gap between cloud and the bricks or is there not? No, then can we step around it? It is a yes or no question. Are you above the lowest safe height for operating in cloud? It is a yes or no question. If one cannot 'see' a clearly defined 'road ahead' then one is obliged to turn away into 'suitable' conditions; or 'better' than that ahead. It is 'unwise' to persist into cloud without a safe height and/or wriggle room, thereby intentionally closing the only exit available - that being the one you just left behind.

ATSB Bollocks #4 - "The first helicopter broadcast to Mr Neal he planned to perform a U-turn, with Mr Neal descending and hovering as the first pilot turned back."

Consider this situation; carefully, from the beginning, start at the very basic level. Begin with the CASA accepted 'operations manual' find the section which defines company policy and the 'does, don'ts of operational procedures/practice. Now then, turn to the page which outlines 'tandem' or 'formation' or 'following' where two aircraft are dispatched to the same destination; in sketchy weather conditions under the Visual Flight Rules. Can you find a clearly enunciated section defining the procedure for when the 'lead' aircraft has 'inadvertently' entered cloud and is reversing track? No? Think on it. The 'following aircraft is in close proximity to the same 'weather'; can't descend too much due to 'the bricks'; can't climb lest the aircraft 'inadvertently' enters 'cloud' - so that aircraft is 'boxed-in' on track trying to peer into cloud to see the opposite direction aircraft emerging from that same area. Russian roulette? anybody? OK, so now try to find the section which outlines a 'sensible' approach to this scenario. What about say a 12 minute delay between the two aircraft? Say based on 80 knots; that provides a 16 mile separation and, the all important 'time' element for the lead aircraft to safely leave the cloud which had been 'inadvertently' entered, with the following having time, space and visibility to avoid the 'opposition'. There are several different ways to avoid increasing the risk to an unacceptable level; whichever 'system' is used can be tailor made to suit the proposed operation. This accident is the second of it's kind now. Have the ATSB or CASA come up with suggestions, solutions or even some sage operational advice?

ATSB Bollocks #5. "Records retrieved from Mr Neal’s craft indicated he then attempted to perform a “steep turn” to exit the cloud quicker, but instead plunged to the ground and struck an old growth tree before bursting into flames."

The high body count, world wide due to similar situations is worthy of note; it is one of the longest standing 'events' and continues 'unabated'. Research shows a couple of clearly defined 'patterns' of experience level and of early 'training'. Many of these pilot's encounter with 'real' weather' is their very first; often actions are based on previous encounters with a lighter weight (for wont of better) of weather; got away with it before - so, push on and chance my (dumb) luck. Many start and finish their training in 'good' conditions; sat in the crew room during the 'bad'. Weather flying 'experience' reduced to reading and listening. Only my opinion, but I believe that aspirant pilots need to 'educated' from the 'get-go' in weather appreciation and operation. (End of Hobby horse ride)...

ATSB Bollocks #6. "A new report by the Australian Transport Safety Bureau released this week found Mr Neal and the second pilot were not qualified to fly in rough weather and held concerns about the conditions before the trip."

What a pointless, artificial cop out. There was no surprise 'found' about the qualifications - it was clearly printed on their bloody licence. VFR - Visual Flight Rules. The requirements for 'legal' operation clearly, with criminal penalty attached, are spelled out in the regulations. I sincerely doubt there is a pilot in the world who has not 'pushed' the specified limits or at least given them a gentle nudge; however. As DRS Bader said;

“Rules are for the obedience of fools and the guidance of wise men.”

There are times when a gentle 'bending' of a rule may be forgiven; but the thoughtless persistence to continue on, until immersed in cloud, without instrument training or 'auto' something (enter temptation sans 'clear thought' for the way ahead) is piss-potical, in the extreme. Nuff said methinks.

ATSB Bollocks #7. “The significant deviation of the pitch attitude during the turn was likely unintentional and the result of inadequate pilot control due to a lack of instrument flying training and artificial stabilisation,” the report found.

Words fail here; its just twaddle, chicken feed for the media vultures. ATSB is devolving into a top cover PR machine; lots of 'stuff and nonsense' but very skinny (anorexic) when it comes to solutions or resolution, let alone aiding and abetting prevention of repeat performances. Why does ATSB even exist? Gods know CASA have enough 'top cover' and the media will write and promote anything which titillates and sells advertisement.

That is it: rant over. My apologies to my peers and betters who actually know and understand the state of play; but to my simpleton's mind it is clear that this farcical, disingenuous, dangerous approach to and lip service paid to 'real' safety outcomes needs some 'delicate' adjustment of the scales; with big hammer. Standing by for incoming.

Toot - toot.....

Hmmm...remember this from the Senate Angel Flight inquiry in September 2019:



Hmm...what are you waiting for Dr A?? 

Much..much MTF?? - P2

[Sandy Reith]

ATSB quote :-
“… were not qualified to fly in rough weather…”

Gosh I must have missed something along the way of my 58 years in GA. “Rough flying?”

Turbulence penetration speed might be in play here? An airsick passenger perhaps?

Trawling through all the regs, manuals and memory box and can’t find the definition of “rough flying” to help understand the ATSB’s finding. Please tell me the quote is not correct or somehow weirdly out of context.

[Kharon]

Rough weather = rough translation.

That particular phrase is a journalistic version or 'distortion' of the ATSB 'words'. It assumes that the public is as ignorant as the journalist and cannot understand the differences set down between conditions suitable for 'visual' (not in cloud) as opposed to 'instrument' (in cloud) etc. The reporter is only as good as the 'explanation' given and, 'the report' offered

Neither party, (ATSB or media) seem to understand that the event aircraft was operated - deliberately - into an 'illegal' situation, by a pilot unqualified to enter a weather system which demand instrument flight proficiency. QED. When the weather is 'marginal' there is a point where a decision must be made; it is a 'yes' or no' answer; there can be no maybe.

There is also one item (of importance) which although subtle (IMO) matters. A commercial pilot licence qualification specifies (or used to) a minimum number of hours flight solely by reference to instruments; the ability to 'reverse' course (Rate 1 turn through 180') being seen as a mandatory prerequisite for licensing. Having made the decision to enter 'cloud' below a safe height the ability to extricate airframe and passengers from that cloud is an assumed given - or should be. Three serious errors mentioned, but not covered in detail by the ATSB press spiel Item one; entering cloud below a 'safe height'. Item two; the notion (unproven) that the reversal turn was made at a 'steep' bank angle. Item three: that loss of control - speed, bank angle and 'pitch' was 'unintended' implying unavoidable. It begs a question - why a 'commercial' qualified pilot cannot perform, on instruments, a simple 180' reversal turn. If not, why not?  Just saying.

Toot - toot.

[Peetwo]

Latest Su_Spence bollocks on Class 5 medicals etc. - 

From February Fort Fumble briefing:

Director of Aviation Safety, Pip Spence

We're launching into 2024 with the much-anticipated introduction of the Class 5 medical self-declaration scheme.

It allows many private and recreational pilots to self-assess and self-declare without the need to see a doctor.

It's a significant initiative we've been progressing as part of our General Aviation Workplan aimed at reducing unnecessary cost burdens and simplifying regulatory processes.

While the Class 5 won't meet everyone's needs, it was informed by strong feedback to introduce a scheme that didn't involve a doctor, is based on comprehensive risk analysis and a careful examination of what other safety authorities do overseas.

The fact that Australia is the first jurisdiction where pilots will not have to see a doctor or medical practitioner made it difficult to find comparative data on the likelihood of impairment or a related accident.

That's why we've taken an initially conservative approach and put in place operational limitations on what you can do when flying with a Class 5.

We've noted your feedback on the need to keep looking at the operational limitations and we'll continue to gather safety and risk data to inform future decisions on whether we can remove or relax the restrictions.

We’ll be conducting a post-implementation review in 12 months’ time as well as continuing to work on a Class 4 certificate that will create more operational flexibility with the involvement of a GP.

We also worked diligently with the aviation medicine technical working group to arrive at a proposal that ensures regulation is proportionate to risk and is managed appropriately.

We believe our Class 5 medical scheme sets a new global benchmark in terms of trusting pilots to decide on their own fitness without seeing a doctor.

There has been some suggestion we should have simply adopted the UK Civil Aviation Authority’s approach.

Other schemes we examined in the UK, the US, Canada and New Zealand all required some kind of medical involvement, at least in the initial application or through requirements to have previously held a medical certificate.

The US BasicMed, for example, requires pilots to be examined by a state-licensed doctor every 48 months and to take an online education course every 24 months.

Our self-assessment will require applicants to complete and pass an online test and meet fitness and eligibility requirements before self-declaring. You will only need to see a health practitioner before applying if you are uncertain of your health status.

The new scheme does not cover less common activities such as aerobatics, formation flying and night visual flight rules operations, however these will be considered as part of the post-implementation review.

The limitations include a 2000kg limit on the maximum take-off weight of aircraft that can be flown under the scheme, which covers more than 70% of GA aircraft.

The number of people allowed on board is restricted to 2, drawing on the safety record established through the Recreational Aviation Australia self-declaration with passenger endorsement and the existing CASA RAMP C medical certificate.

More details on how the Class 5 scheme works are available on our website.

The new scheme joins a growing list of GA Workplan initiatives we’ve introduced over the last 2 years.

We’re taking the opportunity to refresh the plan and we’re looking for your input into future areas of focus.

We want to hear about the initiatives you believe should be included in ‘GA Workplan 2.0’ as we continue our push to safely reduce unnecessary regulatory burdens and minimise costs where possible.

We’ll also be looking for ideas in the vast amount of information sent to us in the consultations we’ve already conducted, and we’ll be brainstorming within CASA.

We’re particularly interested in initiatives that have wide appeal, will affect a large number of people and may not require regulatory change.

This might involve procedural or administrative changes around how we process an application or provision of additional guidance material to assist operators.

We’re keen to hear your views, so check out our GA Workplan website and send your suggestions through to submit improvement to the rules.

All the best,

Pip

(Plus via LMH: https://www.australianflying.com.au/late...-this-week

A response from Sandy...

Perhaps reading Ms. Spence’s semi apology for the Class 5 with some truly weird discombobulated (?) ramblings will numb your brain and thus provide some comfort. 

Example this ‘world’s first’ no medical exam standard will be limited to two onboard because of the good record of RAAUS (40 yrs has no aviation medical). 

Apparently having more passengers increases the accident rate. It would be interesting to know the RAAUS accident rate compared to the VH private rate. 

MTF...P2 

[Peetwo]

Su_Spence BIAS a BEER files: Croc Wrangler on more charges??

Previous AP reference:  Croco-shite cover-up: Su_Spence surveillance and Board bias??

Yesterday courtesy of the SMH:

Outback Wrangler Matt Wright hit with fresh charges over fatal crash

By Neve Brissenden
February 8, 2024 — 2.56pm

Outback Wrangler star Matt Wright and his aviation company have been hit with a slew of new charges over a fatal helicopter crash that killed his co-star.

Chris Wilson plunged to his death in a remote area of the Northern Territory in February 2022 while attached to a helicopter owned by Wright and being flown by pilot Sebastian Robinson.


Chris “Willow” Wilson (left) and Matt Wright as seen in their reality television series before the fatal helicopter accident.

Robinson survived but was critically injured in the crash.

The NT’s workplace safety watchdog charged the celebrity croc-wrangler and his aviation company Helibrook with “reckless conduct for operating unsafe aircraft” on Thursday.

The watchdog said while a police investigation was yet to determine the cause of the crash, it found “sufficient evidence” that Wright made up the number of flight hours his aircraft had done, and put his passengers and pilots at risk.

“He engaged in conduct intended to falsify the actual number of flight hours accrued by the aircraft in the Helibrook fleet over an extended period of time,” NT WorkSafe said in a statement.

“This ... impacted the regular inspection and replacement of the aircraft’s life-limited components ... therefore placing at risk the health and safety of the pilots and passengers.”

Helibrook Pty Ltd and Wright have each been charged with two counts of reckless conduct.

The WorkSafe charges are the latest of Wright’s latest legal battles, as he prepares to fight criminal and civil charges this year.

Wright and his pilot Michael Burbidge were allegedly first on the scene of the fatal crash in 2022, accompanied by former senior NT police officer Neil Mellon.

The three men were all later charged with perverting the course of justice and destroying evidence.

Wright will go to trial in the NT Supreme Court on one count of perverting the course of justice.

Another six charges, which include tampering with evidence and threatening pilot Robinson, are yet to be heard though Wright denies any allegations of wrongdoing.

He is also facing a civil case, filed by Wilson’s widow Danielle Wilson.

Ms Wilson is suing Wright and the Civil Aviation Safety Authority for alleged “wrongful acts or omissions” that caused or contributed to her husband’s death, Federal Court documents provided to AAP have revealed.

She is seeking costs, damages, interest, interest on costs, and “such other order as the court sees fit” for the psychological harm caused by the conduct.

– AAP

Hmm...



...TICK TOCK goes the Su_Spence 'PLEASE EXPLAIN' clock??   

MTF...P2 

[Peetwo]

Su_Spence BIAS a BEER files: Wilson Widow freezes Croc Wrangler assets -

Via the Oz:

Fresh blow for Outback Wrangler star Matt Wright as court considers order to freeze assets



Outback Wrangler star Matt Wright faces having his assets frozen, while a civil case is heard against him and his company Helibrook in the Federal Court.

Mr Wright is also facing charges brought by the Northern Territory workplace health and safety regulator over a helicopter crash at King River on February 28, 2022 that killed his friend Chris Wilson, and left pilot Sebastian Robinson a paraplegic.

Mr Wilson was in a harness beneath the helicopter for the purpose of collecting crocodile eggs when the helicopter came down.

Both Mr Wilson, a father of two, and Mr Wright appeared in Outback Wrangler, as well as ten episodes of the Netflix reality series Wild Croc Territory.

An Australian Transport Safety Bureau investigation found fuel exhaustion to be the most likely cause of the crash, and that Mr Wilson’s harness was released from the helicopter above a survivable height.



The ATSB’s final report also made damning findings about Helibrook’s safety management system, and failings by the Civil Aviation Safety Authority to ensure appropriate and adequate risk management.

On the back of those findings, Mr Wilson’s widow Danielle launched civil proceedings against CASA and helicopter company Helibrook, and was now seeking to add Mr Wright to the action.

A hearing before the Federal Court on Thursday, was told an interlocutory application had been filed “joining” Mr Wright to the case, and seeking a “freezing order” on the reality TV star and his wife Kaia.

Barrister David Lloyd SC for Ms Wilson, said they were hoping to get an undertaking about “not transferring or disposing of assets” while the case was being heard.

He said it was yet to be determined if Helibrook was insured for the crash, which prompted the freezing order.

Barrister Tom Brennan SC for Helibrook, said “the insurer needed to consider its position and make clear to Helibrook what its position is”.

“If that’s to decline liability, your honour won’t be seeing me,” said Mr Brennan.



Justice Elizabeth Raper agreed to hear submissions for the order next Tuesday, February 20.

The move to have Mr Wright face civil proceedings followed additional charges laid by NT WorkSafe last week, including two counts of reckless conduct.

The charges relate to allegations Mr Wright interfered with the helicopter’s internal meters and falsified flight records over a period of time.

NT WorkSafe noted that if found guilty of all charges, Helibrook faced a maximum penalty of $6m, and Mr Wright faced a maximum $1.2m fine, or five years jail or both.

The matter was listed for mention in Darwin Local Court on February 27.

"..The ATSB’s final report also made damning findings about Helibrook’s safety management system, and failings by the Civil Aviation Safety Authority to ensure appropriate and adequate risk management..." - Including the DAS Su_Spence and the former Chair of the Board...

Outback Wrangler's Matt Wright, Mick Burns met with CASA bosses before Chris Willow Wilson chopper crash



Just months before Netflix star Chris Wilson’s death, an insider arranged a meeting between CASA bosses and Outback Wrangler pair seeking flight rule expemptions, emails reveal.

---

CASA denies responsibility for fatal Outback Wrangler chopper crash that killed Netflix star Chris Wilson

The Civil Aviation Safety Authority denies responsibility for the fatal chopper crash that killed Netflix star Chris Wilson because the destroyed helicopter “should not have been operating at all” when it crashed.

MTF...P2