[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