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Postscript to Pel Air

On 28 June 2017, a Socata TB-10 Tobago aircraft crashed after take-off, killing the pilot and two passengers (ATSB, 2019). The flight was organised by a charity, providing transport from remote areas for people needing to visit hospital, known as community service flights (CSFs). Volunteer pilots provided their services and the use of their aircraft and, on the company’s website, were described as ‘Our Heroes’. The 78-year-old pilot of the Tobago was qualified for flight under visual flight rules but did not hold an instrument rating. He had departed Murray Bridge Airport, South Australia, at 0800, arriving in the area of Mount Gambier Airport at around 0940. The weather at the time was overcast at 200ft agl. Having descended through cloud, the aircraft was seen by observers and caught on CCTV, manoeuvring at low level.

After two attempts, the pilot landed and collected his passengers. Visual flight rules require a non-rated pilot to remain clear of cloud. At the time of take-off, both the horizontal visibility and the presence of complete overcast rendered the flight technically illegal, given the license held by the pilot. Nonetheless, he took off at 1020 and crashed 65 seconds later. The final ATSB report contained seven findings, two relating to the pilot’s actions, one relating to CASA’s oversight of CSF operations and four relating to the charity that organised the flight.

The ATSB undertook an extensive analysis of accident rates for different types of operations and demonstrated that flights conducted by the charity were significantly more risky than other private flights. Operations conducted by pilots with private licenses were, in turn, more risky than commercial flights. The report drew attention to this fact and also commented on the need for greater risk management and for, possibly, tighter regulation by CASA.

The response was swift in coming. The report was dated 13 August 2019. Within days, the CEO of the charity had appeared in the media claiming that, among other things, ‘The ATSB offered no safety recommendations to pilots flying light aircraft in bad weather’; that ‘it is regrettable that the Bureau made no relevant safety recommendations, nor gave any guidance whatsoever, to pilots flying in poor weather conditions - the cause of the accident’; that ‘its Pel Air (Norfolk Island ditching) all over again - for that particular report the ATSB were found to be grossly incompetent and were ultimately required to redo the report’. In what can only be seen as a significant attempt to deflect criticism, the ATSB was cast in the role of a culprit. Supporters of the charity took out full-page newspaper ads to protest against the findings, and lobbying was successful in achieving yet another Senate inquiry into aspects of the analysis of the accident by the ATSB. The subsequent report (Commonwealth of Australia, 2019) accepted the technical analysis of the event but criticised the ATSB’s use of statistics to identify CSF operations as being of higher risk.

After this accident, CASA introduced guidance on the minimum qualifications of pilots and also a slightly more stringent maintenance requirement for inspections at 12 months or 100 in-service hours. Given that most CSF operations were conducted using privately owned aircraft, and it was found that few such aircraft actually accumulated more than 100hours in 12 months, this was hardly an onerous change, but it drew criticism from the inquiry. In a telling comment, one of the inquiry- participating members stated that ‘Angel Flight cannot be disrupted by unnecessary regulation’. Further, he said ‘CASA has an over regulation issue (my italics)’ and that it should ‘treat safety as primary, but be mindful of the need to maintain a healthy industry. In the past, CASA regulations have drowned general aviation, and that has to change’ (Parliament of Australia, 2019).

This sequence of accidents, from Lockhart River through Norfolk Island to Mount Gambier, illustrates how investigation and regulation increasingly have to negotiate a public discourse that can be politically motivated and contradictory. The ATSB was criticised after Norfolk Island for not saying enough about the organisational factors and the role of the regulator. After Mount Gambier, the ATSB was criticised for going too far into organisational factors and not saying enough about how to stop unqualified pilots attempting to fly in unsuitable conditions. Some of the criticism seemed to reflect a fundamental lack of understanding of the role of the regulator in licensing pilots and the duty of the pilot that flows from holding a license.

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