016/18

Status
Open
Recommendation Date
Recipient Name
Way To Go
Text
The operator did not have adequate systems available for the pilot to determine the actual all-up weight and balance of the helicopter for the firefighting operation, or to ensure that incidents such as the previous loss of a window were recorded, notified to the CAA and investigated. The use of a prohibited door configuration suggested inadequate awareness of and adherence to flight manual limitations, which often differ between otherwise similar variants of an aircraft.

On 23 May 2018 the Commission recommended that the chief executive of Way To Go Heliservices review the company’s internal quality assurance system to ensure that:
- there are robust systems in place for establishing the actual weight and balance of all company aircraft for all operations
- incidents and accidents are recorded, notified to the CAA and investigated, and corrective actions are taken as appropriate
- pilots are fully aware of and observe the operating limitations of all the aircraft types and variants that they fly.
Reply Text
Way To Go confirms that it will implement the final recommendation contained in your letter of 25 May 2018. Way To Go expects the recommendation will be fully implemented by 30 September 2018.

By way of general comment, Way to Go has been progressing towards the implementation of Safety Management Systems and is focussing on risks that impact on safety. In addition, a ‘Just Culture’ environment has been introduced and embraced by Way To Go over the past few years.

Weight and balance
Way To Go maintains that its weight and balance system was understood and used by pilots on an operational basis. However, Way To Go was working on and has introduced a modification to Aerial Toolbox to include a weight and balance calculation on each daily flight record that is a visual reminder of the operating limitations of the aircraft being flown. This tool is currently in its testing stage and should be ready for full functional use by 30 September 2018.

Incidents and accidents
Way To Go has recently updated the Aircare qualification. This has resulted in modifications and additions to the Quality Assurance system including a Reported Quality Improvement register, clear goals for Internal Audit processes, and requirements for documentation of responsibilities and follow ups from staff and executive meetings.
These changes reflect formally documenting the processes Way To Go has always followed.

These changes will be internally audited for effectiveness in the quarter ending 30 September 2018.

Operating limits
Way To Go relies on the annual Flight Competency Check and the six monthly Competency Check for recording Pilot Training of operational limitations of aircraft. Way To Go has always documented these but has now also made recording compulsory of informal Pilot Toolbox and Crew Meetings which will help ensure records can prove Crew
Training understanding.
The company is in a change period for Crew Training Manager and is reviewing a Procedural Update for Crew Training along with Risk Assessment documentation. Way To Go is also currently evaluating other procedural changes required to ensure personnel that are trained and competent in safety responsibilities are documenting such fully.

Reporting to TAIC
Way To Go will write again setting out the date when the recommendation was fully implemented, a brief description of how it was implemented and evidence to support its implementation.
Related Investigation(s)