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The results of a federal investigation into one of the worst adventure tourism accidents in Australia, who killed four people in World in Gold Coast, have been released after a two -year investigation.
The Australian Transportation Security Office published its final report on the fatal collision in the air of two panoramic flight helicopters, which operates in Queensland’s theme park, in January 2023.
An experienced pilot and three passengers died, while a second pilot and five passengers were seriously injured, when two Eurocopters, who made five -minute joy flights, collided near Main Beach on January 2 of that year.
The final 200 -page report on the fatal accident has highlighted the importance of “multiple defense layers” in commercial aviation and makes 28 findings that “highlight the key lessons for operators and pilots.”
The ATSB chief commissioner, Angus Mitchell, said that the most fundamental lesson of this investigation was to make changes in aviation operations, even those that seem to increase security, may have unwanted consequences.
“Therefore, it is critical that changes in aviation operations are administered by implementing a defined process to ensure that general security is not negatively affected,” he said.
The catastrophic accident occurred a week after the helicopters Sea World began to use the two Eurocopter EC130 helicopters for their scenic flight operation.
“In the months prior to this tragic accident, the operator had made changes to improve its tourist product, including the implementation of the use of a second location of Helipad, known as Park Pad, the introduction of the largest EC130 helicopters and the new Hangar and offices facilities,” Mitchell said.
“Over time, these changes undermined the risk controls used to manage traffic separation and created a conflict point between launch and departure helicopters, which is where the two helicopters collided.
“The operator’s security management system did not effectively manage the safety risk present in its aviation operation, and when numerous changes were introduced, it did not implement processes to consider whether they would affect the general security of their flights.”
The report describes that in the period prior to the collision, an incoming call of the helicopter that arrives could not register with the pilot of the helicopter that came out, which was busy carrying passengers in the park’s pad at that time.
Once the passenger load was completed, a member of the land crew informed the helicopter pilot that it came out that the airspace was clear.
“However, this advice was no longer accurate when the helicopter took off more than 20 seconds later, since the incoming helicopter continued its approach to the earth,” Mitchell said.
“In addition, the maneuver restrictions on the park’s pad and the closing angles of the two helicopters limited the visibility of the pilot that comes out to identify the helicopter that is approaching.”
The incoming helicopter pilot had previously seen the helicopter that came out on the park pad, but had evaluated that it was not a threat, and expected it to be alerted by a radio call of ‘filming’ if that condition changed, which would be his signal to organize the separation.
“The ATSB found failures in the helicopter radio antenna that probably prevented the transmission of the taxi call,” Mitchell said.
“Without receiving the filming call, the incoming helicopter pilot, who was probably focusing on his landing site, did not have a trigger to reassess the state of the helicopter that comes out as a risk of collision.
“This agency emphasizes that aviation operations must have multiple security defenses and not be vulnerable to individual failure points, such as defective radios, or the capacity of a pilot to detect another helicopter in a visually restricted environment.”
A visibility study by the ASB, which validated the cross -on -board flight data with images of multiple cameras on board and outside the helicopter, confirmed that the view of both pilots of the other helicopter was limited in the period prior to the accident.
“This limited visibility combined with the competitive priorities of the pilots and the understanding of airspace was clear, it led to collision in the air since both helicopters went through the conflict point created by the introduction of a second heliport nine months before,” Mitchell said.
“While the operator had a radio call system, manual signals and visibility devices that intended to alert pilots of the presence of another helicopter, the investigation found that the system had significant defects.”
The report details that the operator has taken a series of security actions in response to the accident.
These include the introduction of a ‘Almohadilla Chief’, a new earth personnel to provide traffic advice information, show positional information from other airplanes (using ‘ADS-B in’) on a map screen on their helicopters (using iPads with EFB), new radio call protocols and adjusting its helicopters with starbrobe lighting and applying a high Visibility of paint of revision rotors.
“We recognize the significant security actions taken to date, however, the ATSB is making four security recommendations to the world’s helicopters to address the remaining security problems,” Mitchell said.
“These recommendations include the formal consideration of conflict points design to identify opportunities for greater risk controls or their elimination; develop objectives within their security management system to focus on the risk of aviation security; improve change management processes; and clarify their change management procedure to capture the introduction of additional helicopters.”
Mitchell said that the survival of the occupants was another key focus of the investigation, which found that the passenger safety belts were incorrectly adjusted due to the interaction of their life -saving vests with their seat belts.
“While ATSB could not determine to what incorrectly adjusted safety belts contributed to passenger injuries, we know that properly adjusted restrictions improve the survival capacity for passengers in case of collisions.”
The research report indicates that there is no easily available guide, either of the manufacturers of life vests or the regulatory authorities, with respect to the correct adjustment and the use of constant life vests when the occupants use multipoint safety belts.
“The occupants in the helicopter tourism operations worldwide run the risk of increasing injuries in an accident due to the incorrect use of the safety belts,” Mitchell concluded.
“Aviation security is based on carefully considered mitigations and defenses for all reasonably predictable risks.
“As such, trust should never be in individual defenses, especially those related to human performance.”
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