The investigation into the helicopter crash in Australia, which resulted in the deaths of four individuals, including a British couple, has concluded. The victims included Ron and Diane Hughes from Liverpool, who were visiting family, along with pilot Ashley Jenkinson and Sydney resident Vanessa Tadros.

The Australian Transport Safety Bureau (ATSB) released its report, identifying 28 findings and highlighting significant safety procedure flaws. The Chief Commissioner emphasized the importance of managing changes to aviation operations carefully to avoid unintended consequences and ensure overall safety.

The report revealed that a crucial radio call was missed by one of the pilots shortly before the accident. Additionally, a series of changes implemented by Sea World had weakened safety measures over time. Contributing factors included a faulty radio antenna and limited visibility.

The operator had introduced several changes, such as larger helicopters, a new hangar, and a second helipad. These modifications, over time, undermined risk controls designed to manage traffic separation, creating a conflict point where the two helicopters collided.

In the moments leading up to the collision, the inbound helicopter's call was not heard by the departing pilot, who was occupied with loading passengers. A ground crew member incorrectly advised the pilot that the airspace was clear. The departing pilot's visibility was also restricted due to maneuvering limitations at the helipad.

The safety watchdog emphasized the need for multiple safety procedures to prevent single points of failure, such as faulty radios or visibility issues. The existing system, which relied on radio calls, hand signals, and visibility devices, was found to have significant flaws.

Both pilots had limited visibility of each other's aircraft leading up to the incident. This, combined with competing priorities and the belief that the airspace was clear, ultimately resulted in the collision.

A previous report indicated that pilot Ashley Jenkinson had used cocaine in the days before the crash. The ATSB determined that he would have had the opportunity to recover from any fatigue effects. However, they cautioned about the unpredictable nature of illicit drugs.

Since the accident, Sea World has implemented several changes, including a new "pad boss" position for traffic advisory information, new radio call protocols, strobe lighting, and high-visibility paint on the helicopters.