[Peetwo]

Wrangler chopper fatal goes systemic...err why?? 

Excellent pick up by Kristen Shorten  , via the Oz -  :

Outback Wrangler chopper probe upgraded



By KRISTIN SHORTEN
INVESTIGATIVE JOURNALIST
@itsKShort
7:11PM JANUARY 13, 2023

The Australian Transport Safety Bureau has upgraded its investigation into the fatal helicopter crash that killed Outback Wrangler cast member Chris Wilson and delayed the release of its final report into the incident by up to six months.

After almost 11 months of work, the ATSB this week quietly upgraded its investigation from “defined” to “systemic”, which means it is now looking at “organisational processes, systems, cultures and other factors” and expects to identify “several safety issues” in its final report.

Wilson, 34, was killed when the Robinson helicopter from which he was dangling during a crocodile egg-collecting mission crashed in a remote part of West Arnhem Land, in the Northern Territory last February.

The father of two had been strapped into a harness attached to a 30m line to collect crocodile eggs when the chopper hit terrain about 30km south of South Goulburn Island. Pilot Sebastian Robinson, who suffered severe spinal injuries, is still recovering.

The destroyed R44 Raven II, registered VH-IDW, was owned and operated by Outback Wrangler star Matt Wright’s company Helibrook.

Mr Wright flew to the scene immediately after the crash with Darwin publican Mick Burns, who owns the crocodile-egg harvesting business, and former senior NT policeman Neil Mellon.

Multiple agencies – including the ATSB, the Civil Aviation Safety Authority, NT Police and NT WorkSafe – are still scrutinising what happened before, during and after the fatal crash.

The ATSB’s investigation was originally considered “defined” but was last week upgraded to “systemic”, which has a broader scope, involves “significant effort collecting evidence across many areas” and often spans multiple organisations.

“Occurrences and sets of transport safety occurrences investigated normally involve very complex systems and processes,” the ATSB website says.

“In addition to investigating failed and missing risk controls, systemic investigations may also investigate the organisational processes, systems, cultures and other factors that relate to those risk controls, including from the operator, regulator, and certifying and standards authorities.”

Systemic investigations are only one level below “major” ­investigations, which is the most serious category and reserved for incidents involving many casualties.

The national transport safety investigator had originally planned to release its final report into the incident by the end of last year but this week pushed the deadline for publishing its findings to June.

This comes as the three men charged in relation to the crash are due back in court on January 25.

NT Police charged Mr Wright in November with attempting to pervert the course of justice, ­destroying evidence, fabricating evidence, unlawfully entering a building, unlawfully entering a dwelling, making a false declaration and interfering with witnesses in a criminal investigation or court process by making threats/reprisals.

The charges relate to the ­celebrity croc-wrangler’s actions after the chopper crashed and ­include allegations that he tampered with evidence at the remote crash site. The 43-year-old has denied any wrongdoing.

In September bush helicopter pilot Michael Burbidge, who was on the crocodile egg-collection mission and discovered the downed chopper before landing at the scene, was charged with conspiracy to pervert the course of justice, attempt to pervert the course of justice, destruction of evidence and providing a false statement in a statutory declaration.

Mr Mellon was charged in ­August with more than 30 offences, including making a false statement, the destruction of evidence and conspiracy to pervert the course of justice.

Note that on the ATSB webpage for this accident - see AO-2022-009 - there is no longer any date stamp (at the bottom of the page to indicate) there has been an update. Nor is there any statement in the text indicating an update, just the change in the 'investigation level' to 'systemic' and possibly a change to the 'anticipated completion' to Q2 2023?? So it is an excellent pick up by Kristen but the fact that it takes an investigative journo to discover such significant changes to a ATSB accident investigation is simply not good enough.

Here was the media statement that accompanied the 20 day late preliminary report:

The ATSB has released a preliminary report from its on-going investigation into a fatal accident involving a Robinson R44 helicopter at King River, in the Northern Territory’s West Arnhem Land.

The report notes the helicopter was one of three conducting crocodile egg collection, able to carry a crewmember (‘sling person’) attached to a 100 ft long line to access crocodile nests.

All three helicopters had departed a staging area at King River to start egg collection from nearby nests on the morning of 28 February 2022.

“Crewmembers of the other two helicopters became concerned when they had not heard any radio communications from the third helicopter,” ATSB Director Transport Safety Stuart Macleod said.

One of the pilots elected to return to the area the third helicopter was operating in, and found the wreckage at a paperbark swamp approximately 300 m from the staging area.

The sling person was found approximately 40 metres from the main wreckage, and was fatally injured. The pilot was seriously injured, and was airlifted to hospital.

“Preliminary analysis of the site by ATSB investigators indicated the accident sequence had occurred while the helicopter was travelling in a north-west direction, shortly after it left the staging area,” said Mr Macleod.

“Initial assessment indicated the engine had stopped prior to the helicopter colliding with the ground,” Mr Macleod continued.

There was no visible damage to the tail rotor blades and drive system and flight control continuity was established.

An examination of the engine and associated components found no defects likely to result in engine stoppage. The helicopter’s two fuel bladder tanks were intact despite breaches of the surrounding metal tanks, and there was no fire.

After initial assessment, the wreckage was removed from the site, and ATSB investigators drained about 250 ml of fuel from the main tank’s bladder.

It was possible fuel escaped into the creek that flowed beneath the wreckage as the fuel system was compromised in the accident, the report notes.

“This preliminary report details factual information established in the investigation’s early evidence collection phase, and as such does not detail analysis or findings, which will be outlined in the investigation’s final report,’ Mr Macleod said.

“As the investigation progresses, the ATSB will include review and examine of electronic components retrieved from the accident site.

“Fuel system components, refuelling practices and fuel quality will also be reviewed and examined, as well as relevant maintenance records, operational documentation and regulations.”

Survivability aspects of the accident will also be considered.

Read the report: AO-2022-009 Collision with terrain involving Robinson R44, VH-IDW King River, Northern Territory, on 28 February 2022

Publication Date
19/04/2022

---

Further investigation

The investigation is continuing and will include review and examination of:

• electronic components retrieved from the accident site
  
• fuel system components
  
• refuelling practices
  
• fuel quality
  
• maintenance records
  
• operational documentation
  
• regulations
  
• survivability aspects.
  

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.

A final report will be released at the conclusion of the investigation.

All of the above indicates (other than perhaps some regulatory issues IE CASA's job to investigate) to me a fairly straight forward 'defined' investigation. So what's changed to justify an expensive taxpayer funded (100s of thousands of dollars??) upgrade to this investigation?? 

MTF...P2