[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

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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...

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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 ???

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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.

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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?? 

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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