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Popinjay to the rescue on Croc Wrangler R44 fatal? - 

Via PJ HQ:

ATSB releases King River crocodile egg collection helicopter accident investigation report



The Australian Transport Safety Bureau has released the final report from its transport safety investigation into an accident involving a Robinson R44 helicopter being used in the collection of crocodile eggs near the Northern Territory’s King River on 28 February 2022.

The ATSB investigation determined that the helicopter’s engine stopped in flight, probably due to fuel exhaustion. During the subsequent autorotation emergency forced landing procedure, the pilot released the hooks and sling line carrying an egg collector beneath the helicopter.

The egg collector was released above a height that would likely be survivable, the investigation found. And with insufficient main rotor energy to cushion the landing, the helicopter collided with the ground, and the pilot was seriously injured.

“Based on an analysis of fuel samples and other evidence, the ATSB investigation found that the helicopter was likely not refuelled at a fuel depot about three quarters of the way between Darwin and the crocodile egg collecting area, and that the pilot did not identify the reducing fuel state before the helicopter’s engine stopped due to fuel exhaustion,” said ATSB Chief Commissioner Angus Mitchell.

“As such, this accident illustrates the importance of effective fuel management, which is especially critical when operating a helicopter where a fuel-related power loss offers few safe options.”

The investigation found that the operator was not using its safety management system to systematically identify and manage operational hazards.

“As a result, the operator did not adequately address the risks inherent in conducting human sling operations, such as carriage of the egg collector above a survivable fall height,” Mr Mitchell said.

“In addition, and although not assessed on the evidence as having been contributory to this accident, the operator's history of non-compliance with regulatory requirements, maintenance standards and accurate record keeping, increased the risk level for much of their aviation activities.”

At the regulator level, the egg collection was being conducted under an instrument issued to the operator by the Civil Aviation Safety Authority (CASA) that authorised the pilot to carry a sling person on a 100 foot line attached to the helicopter.

“The ATSB found that CASA did not have an effective process for assuring an authorisation – the instrument issued to the operator – would be unlikely to adversely affect safety,” Mr Mitchell said.

As a result, the ATSB could not find evidence that CASA delegates used the available structured risk management process to identify and assess risks; to ensure suitable mitigations were included as conditions of the instrument; and to assess the effects of changes on the overall risk.

This resulted in removal of the instrument’s mitigating conditions limiting the height, speed and exposure for the sling person, which permitted carriage of the egg collector above a likely-survivable fall height.

“At the operator and regulatory level, effective safety management processes that identify and safely manage hazards are vital to preventing future accidents,” Mr Mitchell said.

“The ATSB notes that the operator has voluntarily ceased commercial helicopter operations, and welcomes that CASA has revised its documented regulatory exemption process, which should assure an adequate level of safety is achieved and documented when approving regulatory exemptions.

“Ultimately, this tragic accident highlights how the actions and decisions of pilots, operators and the regulator can all have a significant influence on aviation safety.”

Read the final report: Fuel exhaustion and collision with terrain involving Robinson R44 II, VH-IDW, King River, Northern Territory on 28 February 2022

Publication Date: 22/11/2023

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:/b] Aviation: General aviation

[b]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??

Incidentally the above safety issues (at this point in time) do not exist as advertised:

The initial public version of these safety issues and actions are provided separately on the ATSB website, to facilitate monitoring by interested parties. Where relevant, the safety issues and actions will be updated on the ATSB website as further information about safety action comes to hand.

More amateur hour, or intentional?

MTF...P2