The ATSB’s 28 findings urge tech upgrades and stricter protocols to prevent a repeat of the Sea World crash and improve aviation safety standards.
The fatal mid-air collision near Sea World was no freak accident.
It stemmed from cockpit blind spots, failed communication, and a dangerously placed helipad, according to the Australian Transport Safety Bureau’s (ATSB) final report released on April 9.
On Jan. 2, 2023, a tragic collision between two Sea World EC130 helicopters unfolded in front of stunned families at the Gold Coast theme park.
The crash killed four people—chief pilot Ashley Jenkinson, New South Wales mother Vanessa Tadros, and British couple Ron and Diane Hughes—and critically injured three others, including two children.
The report found a faulty radio antenna on the departing helicopter severely reduced its transmission range, making it almost certain that the pilot’s taxi call was never broadcast.
Both pilots were also unable to visually detect each other due to structural blind spots in their aircraft.
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Additionally, the reinstatement of a helipad in 2022 created a conflict zone between arriving and departing flights, increasing the risk of a collision.
ATSB Chief Commissioner Angus Mitchell said the investigation produced 28 findings with vital safety lessons for aviation operators and pilots.
“The most fundamental is that even safety-driven changes to aviation operations can have unintended consequences,” he said.
The ATSB has urged improvements in communications technology, electronic alert systems, and visibility enhancements to help pilots overcome the limitations of visual flight rules.
It also recommends formal processes for assessing operational changes and warns against relying solely on human vision in busy, uncontrolled airspace.
‘See-and-Avoid’ Systematically Failed
A cockpit visibility study, conducted with Airbus Helicopters and iwiation GmbH, revealed both helicopters had major blind spots that would have prevented either pilot from seeing the other before the impact.
“This was primarily due to obstruction from the aircraft structure,” said Stuart Godley, director of Transport Safety at the ATSB.
He added that pilot apparel, environmental conditions, and cockpit layout further restricted visibility.
The study confirmed that the “see-and-avoid” method failed by design.
Advanced modelling and analysis of cockpit and external video footage showed that the aircraft structures blocked the pilots’ view in the moments before the crash.
Separate techniques were used to cross-validate findings, ensuring accuracy.
“Multiple data verification processes were employed,” Godley said, noting that the animation and visibility studies were independently verified.
The research reinforced the limitations of human vision in congested airspace and underscored the need for technological support.
“Pilots must recognise these limits and use effective communications, onboard systems, and visual aids to compensate,” he added.
Radio Fault and Outdated Advice Compounded Risk
The report found that the defective radio in Jenkinson’s aircraft, combined with ground crew timing, played a critical role.
Jenkinson received take-off clearance based on airspace conditions that changed just 20 seconds later, and his aircraft’s faulty radio almost certainly failed to transmit his departure call.
Meanwhile, returning helicopter pilot Michael James was unaware Jenkinson had taken off and received no radio warning of potential conflict.
Multiple Failings
The March 2022 decision to reopen a second helipad increased operational pressures and created a persistent conflict zone in the airspace.
Pilots were left juggling unreliable visual and verbal cues without adequate technological safeguards such as functioning traffic alert systems, forcing them to manage unworkable risks.
The ATSB also identified a broader erosion of safety protocols following a change in ownership in 2018.
Over time, key measures—including in-cockpit traffic displays and enhanced communication protocols—were phased out.
“Each individual failing was only one part,” Mitchell said. “You need to put all of them together for this outcome to have occurred, and the outcome could not have been worse.”
Four Key Safety Gaps Remain
Despite some changes by Sea World Helicopters since the incident, the ATSB flagged four major unresolved safety concerns.
Top among them is the need to improve how pilots detect and avoid airspace conflicts.
The agency also called for structured reviews before operational changes, warning that ad hoc decisions can introduce hidden risks.
The findings feed into the ATSB’s ongoing SafetyWatch campaign, which targets collision risks at non-towered airports and broader systemic issues.
