[Peetwo]

Your Honour: The factual evidence is all in the ATSB report??
 
Could I suggest that 'Thirsty', courtesy the UP, maybe channeling Kharon?? -  : https://www.pprune.org/11947703-post33.html

Quote:

Originally Posted by KRviator [/url]
You have to admire CAsA's defence though "But if he did what we told him to do, and complied with 'the roolz', there wouldn't have been an accident!"... So that begs the question what are CAsA's FOI's and regulatory enforcement muppets for? if not to surveil the industry to specifically ensure 'the roolz' are being complied with?? Afterall, does that not suggest some in the aviation industry don't do what the regulations say, and as a result, the industry requires monitoring? And perhaps, those engaged in high-risk activities more so than Joe Average in his 152?
So where was CAsA in all this?

Quoting directly from the ATSB report:

Quote:

Continued unmitigated operational risk
As CASA delegates had not formally assessed the operational risk of using an R44 helicopter they continued to approve R44 HEC for crocodile egg collection without assurance that aviation safety was preserved.

and again:

Quote:

This resulted in continuation of what CASA had assessed as an unacceptable ongoing risk.

Quite damning for a safety organisation to be described that way.

The lack of a chain of documentation for years prior to the accident showing how the layers of safety had been assessed, tightened and relaxed, and subsequent CASA personnel assuming that the risk management had been satisfactory assessed by others in the past without the evidence being available is either wilful ignorance, or professional misconduct. There is no third option..The holes in the swiss cheese inevitably started to line up, year by year, approval by approval, until the accident happened.

The response to the ATSB safety issue by CASA is couched in very general terms. Who will regulate the regulator?
Wigs at twenty paces - the legal costs and implications will be enormous.

Long before Helibrook was a twinkle in the Croc Wrangler's eye, CASA promulgated the normalised deviance of approved R44 croc egg collection.

Reference: [url=https://www.atsb.gov.au/sites/default/files/2023-11/AO-2022-009%20Final.pdf]AO-2022-009 Final Report

The Civil Aviation Safety Authority’s approval process

Approval process

Picking up and carrying a person outside a helicopter was not permitted without specific authorisation. CASA could only grant such an authorisation, if doing so would be unlikely to have an adverse effect on safety. To ensure safety was preserved, CASA could impose conditions set out in an authorisation instrument.

Guidance was available for the administrative side of processing a request for an authorisation. However, there were no guidance or tools for conducting the safety assessment to determine whether an authorisation and its conditions assured the preservation of safety. Flight operations considerations for approving an aerial work activity were detailed in the Air Operator’s Certificate (AOC) Handbook, but this did not include the management of risk. The AOC handbook also contained safety management and risk assessment guidance for assessing an AOC holder's SMS, but the CASA delegates contacted by the ATSB as part of this investigation did not consider this relevant to the instrument approval process.

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.

Influence on human external cargo risks

Once the hooks met the required certification standard, failure of the hooks was extremely improbable. As a result, CASA approved amendments to the rotorcraft flight manual supplement associated with the dual hooks. These included the removal of limits for the height and distance a sling person could be carried and an increase of the maximum slinging speed to 60 kt. However, this did not consider circumstances that could result in release of the sling person, other than failure of the hooks.

CASA delegates then removed the HEC limitations from CASA’s instrument conditions. It is unclear why these conditions were removed. However, as a formal risk assessment was not performed it was not identified that there were other failure conditions likely to result in release of the sling person and that the removal of height and speed limits for carrying the sling person significantly increased the overall risk.  

Falls from greater than 5 m above the ground are more likely to result in a fatality. CASA’s removal of those limitations meant that an operator could both operate within an authorisation instrument’s conditions and permit an avoidable fatal outcome for a sling person in the event of an emergency release, such as occurred during this accident.

Continued unmitigated operational risk

As CASA delegates had not formally assessed the operational risk of using an R44 helicopter they continued to approve R44 HEC for crocodile egg collection without assurance that aviation safety was preserved. Although CASA’s RMP assessed that a single turbine engine helicopter with a usage monitoring system had a higher reliability and less likelihood of engine failure than an R44 helicopter, it did not consider or compare the hazard of fuel exhaustion.

Having formally assessed the risks for the RMP in 2013, the following year, CASA Flight Standards Branch personnel engaged with operators who conducted HEC for crocodile egg collection and advised of CASA’s intent to require a turbine helicopter with a usage monitoring system for improved helicopter reliability. CASA personnel then drafted the relevant legislation and engaged with the industry before it was finalised. Although operators had been notified and engaged during the rulemaking process, shortly prior to commencement of the regulations in 2021, a CASA delegate issued Helibrook with a 3-year instrument approving continued use of an R44 helicopter for human slinging operations. This resulted in continuation of what CASA had assessed as an unacceptable ongoing risk.

Then to top off CASA's overseeing (Reason Model) culpability in this tragic accident, they then mentored and ultimately approved, without proper review or surveillance, a Helibrook AOC SMS:

Helibrook safety management

Helibrook had introduced a CASA-accepted safety management system (SMS) in conjunction with CASA’s approval of the Helibrook chief pilot. This included purchase of a third‑party produced SMS manual and assigning the operations manager to also perform the safety manager role. The SMS manual stated that through the SMS, Helibrook would identify hazards and risks, with the goals of minimising risk, maintaining the health of stakeholders, and continually improving safety.

An assessment of the operator’s SMS following the accident quickly identified that in the 2 years since its approval, Helibrook had not implemented the system described in the SMS manual. Time or resources had not been allocated to safety management tasks, and the safety manager’s priority had been to fulfill their other role as operations manager. There was no evidence of a maturing safety culture, in which effective hazard identification enabled actions to proactively manage risks and prevent accidents. No formal, documented risk assessment had been conducted for any of Helibrook’s approved activities, including human external cargo (HEC) operations. As an operator conducting a specialised high-risk activity, application of the SMS would have assisted the identification of hazards and risk controls to reduce the risk of harm to operating crew.
CASA’s approval to conduct HEC operations required the pilot and egg collector to assess that the risk of heat illness and crocodile attack outweighed the risks of slinging. A structured risk process would have provided a means for this assessment to be made as well as identifying occasions when slinging was unacceptably risky. The same process should also have identified mitigations to reduce the:

• likelihood of an emergency event occurring, such as:
  
  • good maintenance practices and adherence to operating limitations to ensure ongoing helicopter airworthiness
    
  • ensuring that required pilot briefing and training in HEC operations were conducted, including fuel management
    
  
  
• consequences of an in-flight emergency, such as height and speed limits for carrying the sling person, and fitting the helicopter with an emergency locator transmitter.  
  

In not using their SMS, Helibrook did not identify the risks associated with conducting human external cargo operations, particularly the carriage of the egg collectors at non‑survivable fall heights, and ensure they were adequately managed.

Join the dots, check the dates and then add in the fact that certain members of the then CASA Board in June 2021 decided to go on a helicopter joy flight (re overview of HEC OPS) with the Croc Wrangler as PIC - see HERE - and consider the follow on alignment of slices of Swiss cheese holes that followed, culminating in the fatal accident 8 months later on the 28th February 2022 -       

MTF...P2