The family of a 12-year-old girl killed in a helicopter crash in Broome three years ago is calling for drastic changes to the regulation of tourist flights and private pilots after a scathing report from the Australian Transport Safety Bureau outlined a series of failures in the lead-up to the crash.
Warning: This story contains details that some readers may find distressing.
Amber Jess Millar died when the Robinson R44 being flown by 40-year-old Troy Thomas, a well-known local tourism operator, crashed moments after taking off from an industrial site on Antheous Way on the afternoon of July 4, 2020.
Mr Thomas was also killed, while a woman in her 20s and another 12-year-old child were critically injured when the aircraft broke up mid-air.
The ATSB found Mr Thomas was not legally authorised to fly the R44 helicopter at the time of the accident, and that he did not apply the handbook procedure for responding to a tail rotor emergency.
It said Mr Thomas demonstrated acts of non-compliance with multiple aviation safety regulations and operated the helicopter in a way that increased the risk of damage or stress on multiple occasions.
"The ATSB concluded that the pilot's high-risk appetite may have influenced the way the accident flight was conducted," the report said.
In the days before the crash, two pilots had reported experiencing vibrations through the helicopter's tail rotor pedals on separate flights.
But the engineers who investigated the problem only tested the aircraft on the ground, failing to follow a protocol to also inspect it in-flight with a solo pilot on board.
A maintenance requirement to log the issues was also not followed, according to the report, and would have required it to be signed off before flying again.
The report said the crash occurred when a part of the tail rotor gearbox became overstressed, causing it to detach.
"The unnecessary carriage of passengers resulted in a significantly more severe outcome following the in-flight break-up," it said.
Amber's mother, Fiona Benbow, and her husband, Clint, have spoken publicly for the first time since the crash on ABC Radio Perth.
Mr Benbow said it had been an excruciating wait for answers in the two years and nine months since the accident occurred.
"It's been the most drawn-out, painful, soul-destroying experience because obviously being classified you can't talk about the detail that's been gathered through the investigation," he said.
"There's just been more and more delays along the lines.
"And it's very hard because it's this pain, it's this anger, it's this frustration, it's this wanting to get answers and speak publicly that we've had to hold in for so long."
Ms Benbow said she remembered vividly how she watched the chopper take off and moments later come crashing back down.
She said they had had a beautiful morning spent at the beach before Troy Thomas, the owner of the helicopter, suggested going for a scenic flight over Cable Beach.
The family was supposed to be in Bali but travelled to Broome to visit the Thomas family when COVID-19 upset their international travel plans.
Ms Benbow watched as Amber and the other 12-year-old girl climbed into the helicopter with water and snacks packed in their bags for the beach.
But as she walked away toward her vehicle, Ms Benbow heard "the loudest bang I've ever heard in my life".
Moments later she was fighting to save her daughter's life.
"It was like a gunshot going off in my ears and I turned around instantly to see the helicopter spiralling out of control, coming down heavily on Amber's side," she said.
"I could see her face as it tumbled twice, a full circle, and then it hit the ground really, really hard."
She raced to the wreckage and desperately tried to save her young daughter and the others on board.
All four of the passengers were unconscious and Amber was bleeding heavily, and Ms Benbow was unable to pull her from the wreckage because another passenger was on top of her.
Finally she found a knife to cut the harness and was able to pull Amber out.
"I was on my own and I carried her and I lay her under the tree because the ground was so, so hot," she said.
"And the sun was really hot.
"We laid her under the closest palm tree and I told her I was going to save her and I just commenced CPR."
Despite the desperate efforts of Ms Benbow and passers-by, Amber's injuries were too severe.
With the ATSB findings having now been made public, the family is calling for urgent changes to prevent another tragic accident.
They said while the final report by the ATSB had shed some light on the crash, the time it had taken to complete could affect further investigations.
They want Worksafe to launch an immediate investigation and commence a prosecution before a three-year statute of limitations expires in July.
"We do not want her to have died in vain that day," Ms Benbow said.
"We just want to honour her and continue her legacy and make changes if we can."
A Worksafe spokesperson said the organisation was aware of the findings of the final report.
"I have sought to meet with the family to discuss the findings of the investigation," the spokesperson said.
"I have also contacted the ATSB to discuss the findings of the investigation and the report."
The Benbows also want an inquest into the fatal crash and have formally written to the coroner asking for one.
"We need the coroner to call for a public inquiry to look at the processes that failed, the multiple processes that failed, the lack of safety culture that was present, which blows me away," Mr Benbow said.
They will meet with Tourism Minister Roger Cook next week to discuss their wishes and hope to meet with Worksafe Minister Bill Johnston too.
They also want the government to conduct a review of the aviation tourism industry and put in place better regulations in a bid to prevent further deaths.
The ATSB said there was a history of unreported accidents and incidents in Mr Thomas's commercial and private operations.
"These occurrences included two tail rotor strikes in different R44 helicopters, and a total hull loss of another R44 helicopter [VH-ZGY] that resulted in serious injuries to a passenger," the ATSB report said.
In a statement, WA Police said officers in Broome would be able to finalise their report for the coroner now the ATSB findings had been released.
"The technical assessment of the crash undertaken by the ATSB, and their associated findings, will form a crucial part of the police report provided to the coroner," the statement read.
Police said finalising the report was a priority.
The ABC has contacted Troy Thomas's family for a response.
Mr Thomas was a well-known and award-winning member of the local tourism industry.
In 2006 he founded Horizontal Falls Seaplane Adventures but sold the business to Australian company Journey Beyond in 2019 — the same year it won an Australian Tourism Award.
Mr Thomas was also an owner of Swan River Seaplanes, which was launched in 2016 to run scenic flights from Perth.
The R44 helicopter that crashed was registered to a company called Avanova Pty Ltd.
After his death, Mr Thomas was described by Natasha Mahar, chief executive of marketing body Australia's North West, as an "iconic figure" of tourism.
The ATSB said its findings focused on safety factors but should not be read as apportioning blame or liability to any particular organisation or individual.
