source : the age
The company that operates NSW’s firefighting aircraft had deficient safety procedures and an “organisational failure” that prevented it from properly assessing safety incidents, a report from the aviation safety regulator has found.
Coulson Aviation, which was granted a 10-year extension of its contract to operate the state’s fleet of water bombing aircraft last July, was investigated by the Civil Aviation Safety Authority following the crash of a tanker aircraft while fighting fires in Western Australia in 2023. It was the second time in five years that a large firefighting aircraft operated by the company crashed in Australia.
The tail section of a C-130 Hercules aircraft operated by Coulson Aviation that crashed north-east of Cooma in 2020.Credit: Getty Images
According to the 2023 CASA report, obtained under freedom-of-information laws, Coulson Aviation had inadequate investigation, hazard identification and mitigating action procedures, which meant the company may have missed the underlying causes of hazards or led to another accident.
CASA said the company’s reviews of its own procedures “have been inadequate in identifying and addressing operational hazards”.
“The safety reviews/investigations reviewed (in addition to the two hull loss accident reports) highlight an organisational failure to comprehensively analyse incidents,” the air safety agency found after observing Coulson Aviation’s Australian operations in May 2023. “The scope of the review/investigations was limited, resulting in the exclusion of potential hazards and contributing factors that could have led [to] a repeat incident or accident.”
Coulson Aviation said it had since fixed all concerns raised by CASA and was safe to fly.
The burning crash site of a Boeing 737-300 firefighting aircraft operated by Coulson Aviation in Western Australia in 2023.Credit: Air Attack
“These findings are a snapshot in time after a review by CASA,” said Britton Coulson, president of the family-owned Canadian company. “All findings were acquitted within the prescribed timeframes. All observations were addressed, even though CASA does not mandate this, showing Coulson’s proactive approach.”
The NSW Rural Fire Service, which signed a 10-year, $400 million contract with Coulson Aviation in July, said it was satisfied the company had rectified the safety problems identified by CASA.
The company maintains and operates the state’s entire aerial firefighting fleet, which includes a Boeing 737 water tanker, three other fixed wing aircraft and seven water bombing helicopters.
The CASA investigation was launched after a Boeing 737-300 crashed during a firefighting mission in the Fitzgerald River National Park in southern Western Australia on February 6, 2023.
Both pilots managed to escape through the cockpit window with only minor injuries, before fire engulfed the wreckage.
It followed the fatal crash of a firefighting Hercules owned by Coulson north-east of Cooma in southern NSW in January 2020 during the Black Summer bushfires. The three crew members – pilots Ian McBeth and Paul Hudson and flight engineer Rick DeMorgan – were killed.
As well as highlighting Coulson’s deficient work on reviewing incidents and accidents, the CASA report also noted the company had no documented guidance for pilots regarding the flight risk assessment tool – software that is used to calculate how risky a flight is likely to be.
“Without proper guidance on the FRAT, flight crews may not conduct comprehensive risk assessments, leading to the possibility of overlooking potential hazards and inadequate risk mitigation strategies,” the report said.
The Coulson Aviation Lockheed C-130 Hercules that crashed north-east of Cooma. Credit: Coulson Aviation USA Facebook
“The absence of documented guidance on the FRAT in the manual suite poses a safety concern for the organisation.”
CASA also found the Australian branch of the company did not have access to global safety data for its aircraft, such as incident reports and accident investigations, because that information was held by the Coulson Aviation parent company based in British Columbia, Canada.
“The absence of access to safety data hampers the organisation’s ability to conduct thorough risk assessments,” the safety authority found.
“Without a holistic understanding of historical incidents and accidents, Coulson Aviation Australia Pty Ltd may overlook critical safety risks associated with their specialised activities.
“This can result in inadequate safety measures and increase the likelihood of accidents or injuries.”
In another finding, CASA investigators noted the company’s policy was to close off events on its hazard and risk register once they had been forwarded on to another department.
“This does not allow the [safety manager] to know where these events are up to, what action has been taken, nor if that action was effective in mitigating the risk.”
The CASA findings followed an Air Transport Safety Bureau investigation into the fatal Hercules crash in 2020 that found “Coulson Aviation’s safety risk management processes did not adequately manage the risks associated with large air tanker operations”.
Britton Coulson said the company openly communicated with the RFS about operational safety matters.
“We have been fully transparent and communicated all CASA surveillance events and their findings to the NSW RFS,” he said. “The last CASA surveillance event resulted in significantly reduced findings, and Coulson were praised by CASA as the inspectors could see our commitment to continuous improvement.”
The RFS said it relied on CASA to undertake regulatory work in relation to Coulson Aviation, and in addition had its own program of audits on contract compliance.
“The RFS is aware Coulson Aviation has continued to work with ATSB to address safety recommendations,” an RFS spokesperson said.
“The RFS has not been notified by CASA or Coulson Aviation Australia of any restrictions by CASA on the operation of their Air Operating Certificate [AOC].
“The RFS is confident Coulson Aviation Australia comply with the safety requirements and regulations as required by CASA in order to retain their AOC.”
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