[Peetwo]

ATSB, CASA & Dept attempted embuggerance of Angel Flight continues...

Another one for the McDonaught aviation safety shame list...

Via the Accidents Domestic thread:

ATSB Mount Gambier Angel Flight report out -   

Has the Hooded Canary buried Angel Flight? You be the judge, via the ATCB:

ATSB investigation highlights risks of community service flights


Source: Mount Gambier Airport
An Australian Transport Safety Bureau investigation has found that community service flights conducted on behalf of Angel Flight Australia have a fatal accident rate per flight that is seven times higher than for other private flights.

That was a key finding of the first analysis to be undertaken in Australia to determine the relative safety of Angel Flight compared to other private flying operations, after a second fatal accident involving the charity in the past decade.

The analysis was conducted as part of the ATSB’s investigation into the collision with terrain of a SOCATA TB-10 Tobago light aircraft near Mount Gambier Airport, South Australia, on 28 June 2017. The aircraft had departed Mount Gambier in poor weather bound for Adelaide, transporting a young person to a medical treatment appointment on behalf of Angel Flight, accompanied by a family member.

Shortly after take-off the aircraft entered low-level cloud (estimated to be about 200 feet above ground level), and the pilot, who was not qualified to fly in other than visual conditions, probably became spatially disorientated, resulting in a loss of control of the aircraft.

Our analysis of the circumstances of this tragic accident highlights that passengers on Angel Flight community service flights, and indeed their volunteer pilots, are being exposed to much higher levels of risk

About 70 seconds after take-off, the aircraft collided with the ground. Both passengers and the volunteer pilot were fatally injured, and the aircraft was destroyed.

“The ATSB considers that the conduct of community service flights, where volunteer pilots flying private aircraft to transport those less fortunate requiring medical treatment from regional and rural Australia, demonstrates a laudable concern for others,” ATSB Chief Commissioner Greg Hood said.

“However, our analysis of the circumstances of this tragic accident highlights that passengers on Angel Flight community service flights, and indeed their volunteer pilots, are being exposed to much higher levels of risk compared with other types of aviation operations.”

Community service flights operating on behalf of Angel Flight do so as private flights, which the Civil Aviation Safety Authority (CASA) defines as “flying for pleasure, sport or recreation, or personal transport not associated with a business or profession”.

However, the ATSB investigation showed that the rate of safety occurrences, which can be pre-cursors of fatal accidents, was substantially higher for passenger carrying Angel Flight operations than other private operations. This is almost certainly due to pilots operating community service flights on behalf of Angel Flight being exposed to additional operational risk factors.


Source: South Australia Police

These include the potential for pilots to experience perceived or self-imposed pressures to take on what Angel Flight described as ‘missions’ to fly ill, unrelated passengers (rather than family  or friends) at pre-determined times and locations to meet scheduled medical appointments, rather than at times chosen by the pilot.

“Angel Flight did not pressure pilots to fly in conditions beyond their capability, but some circumstances can lead a pilot to feel pressure anyway, such as the responsibility to fly unrelated ill passengers to meet medical deadlines. This can lead to degraded decision making under high-pressure situations, like when confronted with poor weather,” Commissioner Hood said.

On the morning of the Mount Gambier accident two regional airliner flights into Mount Gambier were delayed due to the poor weather, Commissioner Hood noted.

The ATSB’s analysis determined pilots flying on behalf of Angel Flight were more likely to make operational errors when compared to other private operations, particularly associated with flight preparation and navigation, airspace, runway events, and communications breakdowns.
 
“The community could reasonably expect that community service flights would have a level of safety at least commensurate with other private operations, if not higher. However, this investigation has shown that those conducted for Angel Flight are actually less safe than other private operations, let alone charter and scheduled airline flying,” Commissioner Hood said.

Earlier ATSB research has already established that private flying has a fatal accident rate per flight that is eight times higher than commercial charter operations and 27 times higher than low-capacity scheduled airline flying. Further, there have been no fatalities involving a high capacity airliner in Australia in more than 40 years.

“Given the factors identified for the accident at Mount Gambier and previously with another Angel Flight fatal accident in 2011, supported by the differences identified in the analysis of safety occurrences and consistent with findings from investigations of similar organisations in the United States, the ATSB considers that measures must be undertaken to improve existing risk controls,” Commissioner Hood said.

The ATSB commends Angel Flight for initiating some pro-active action on a number of the investigation’s identified safety issues, including developing an online safety course, planning a pilot mentoring program, and implementing a safety management system. The ATSB will continue to monitor the implementation of these and other controls to ensure pilots receive sufficient support and guidance to deal with the additional risks faced by private pilots when conducting a flight on behalf of Angel Flight.

However, the ATSB has issued a formal safety recommendation to Angel Flight Australia, recommending that it consider paying for commercial flights where they are available to transport its passengers.

“This ATSB investigation showed that commercial passenger flight options are available for nearly two-thirds of the private flights organised by Angel Flight,” Commissioner Hood said.

Angel Flight could purchase tickets on commercial flights for two passengers for a comparable cost to the organisation to what they normally reimburse for the fuel costs of privately-operated flights. Taking into account other passenger needs, 30 to 40 per cent of flights could be done using existing commercial flights.

“As a charity established to transport rural and regional people with limited financial means to medical appointments, the ATSB considers that Angel Flight could and should include the fact that commercial passenger flights have a lower safety risk to passengers than private operations as a factor when they are organising flights.”

Commissioner Hood noted that on the day of the Mount Gambier accident, suitable and cost-comparative airline flights were available.
In response to a separate safety issue raised by the ATSB’s investigation, CASA has taken proactive safety action by ensuring community services flights can now be identified separately to other private operations, which will better enable it to identify risks in the sector into the future.

“The ATSB is supportive of the community service flight sector, however, based upon the analysis conducted, it is essential that the controls for risk are strengthened to prevent further accidents,” Commissioner Hood said.

Read the investigation report AO-2017-068: Collision with terrain involving SOCATA TB-10 Tobago, VH-YTM, near Mount Gambier Airport, South Australia, on 28 June 2017 

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And via Oz Flying:






Angel Flight should be using Public Transport: ATSB
13 August 2019

The Australian Transport Safety Bureau (ATSB) has recommended that Angel Flight clients should be placed on regular public transport (RPT) flights rather allow private pilots to fly missions.

The conclusion was part of an investigation report released this morning into the 2017 crash of a TB10 Tobago at Mount Gambier on an Angel Flight mission.

According to the ATSB, the pilot of VH-YTM was ferrying passengers from Mount Gambier to Adelaide in June 2017 when he took off into low cloud and poor visibility. The aircraft reached a maximum altitude of only 300 feet before it descended and struck terrain about a minute after take-off. All three on board were killed. The flight was VFR and the ATSB considered the pilot did not have IFR proficiency.

" ... the pilot took off in low-level cloud without proficiency for flight in instrument meteorological conditions," the report states. "Shortly after take-off, the pilot likely lost visual cues and probably became spatially disorientated, resulting in loss of control of the aircraft and collision with terrain."

Cameras at Mount Gambier airport and GPS tracks showed the pilot conducted a series of non-standard turns during his initial approach to the airport and that conditions were marginal.

Among its findings, the ATSB stated that Angel Flight's incident rate was "considerably more" than other private operations, that Angel Flight didn't have controls in place to address operational risks involved in community service flights and that CASA didn't have a system in place to differentiate between community service flights and normal operations.

"The ATSB found two aspects in particular likely contributed to this higher rate," the ATSB explained. "These were the potential for some pilots to experience perceived or self-induced pressure by taking on the responsibility to fly ill, unknown passengers, at scheduled times to meet predetermined medical appointments, often with an expected same day return; and the required operation to unfamiliar locations, and limited familiarity with procedures in controlled airspace (associated with larger aerodromes)."

The ATSB also slammed Angel Flight for not having placed the passengers on commercial RPT.

"It was identified that Angel Flight did not consider the safety benefits of commercial flights when suitable flights were available, the report states.

"While Angel Flight arranged and paid for commercial flights (18% of all flights) for capital city transfers, or when private pilots cancelled, it was estimated that nearly two-thirds of the private flights conducted for Angel Flight had a commercial regular public transport option available, which offered considerable safety benefits when compared to private operations.

In a media statement accompanying the reports, ATSB Chief Commissioner Greg Hood said that Angel Flight should use RPT as a first resort.
"The ATSB has issued a formal safety recommendation to Angel Flight Australia, recommending that it consider paying for commercial flights where they are available to transport its passengers," Hood said.

“This ATSB investigation showed that commercial passenger flight options are available for nearly two-thirds of the private flights organised by Angel Flight.

"Angel Flight could purchase tickets on commercial flights for two passengers for a comparable cost to the organisation to what they normally reimburse for the fuel costs of privately-operated flights. Taking into account other passenger needs, 30 to 40% of flights could be done using existing commercial flights.

Angel Flight responded to the safety concerns raised in the investigation by saying it considered it inappropriate for the ATSB to criticise them for not abandoning the model for which they were constituted.

"Angel Flight only consider[s] the use of regular passenger transport in two circumstances: if a private pilot is unavailable or cancels at short notice and flights are available, or if the flights are capital city to capital city.

"They are not, and are not required to be, considered other than as a back-up and for long distance compassionate flights."

In March this year, CASA instituted new restrictions on pilots conducting community service flights, which is currently the subject of legal action between Angel Flight and the regulator. The matter has also been listed for disallowance motions in both the Senate and the House of Representatives.

Read more at http://www.australianflying.com.au/lates...toxGB4V.99

Hmm...I find it passing strange that despite the ATSB stating on all active investigations similar words to the effect...

..should any safety issues be identified during any phase of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue...

 
 ...that the ATSB in this case waited till the final report release day to issue a very rare safety recommendation directly to Angel Flight:

Safety issue description

Angel Flight did not consider the safety benefits of commercial passenger flights when suitable flights were available.

Response to safety issue from Angel Flight: Angel Flight consider it inappropriate for [the ATSB] to criticise the charity for not abandoning the model for which it was constituted. Angel Flight only consider the use of regular passenger transport in two circumstances: if a private pilot is unavailable or cancels at short notice and flights are available, or if the flights are capital city to capital city. They are not, and are not required to be, considered other than as a back-up and for long distance compassionate flights.

ATSB comment: The ATSB acknowledges that Angel Flight uses commercial passenger transport for some flights it organises. This ATSB investigation showed that commercial passenger flight options are available for a considerable percentage of the private flights organised by Angel Flight. As a charity established to transport people without the means to medical appointments, the ATSB considers that Angel Flight could and should include the fact that commercial passenger flights have a lower safety risk to passengers than private operations as a factor when it is organising flights.

The ATSB is issuing the following recommendation.

Recommendation

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Action organisation: Angel Flight Australia

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Action number: AO-2017-069-SR-015

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Date: 13 August 2019

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Action status: Released

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The Australian Transport Safety Bureau recommends that Angel Flight Australia takes action to enable it to consider the safety benefits of using commercial flights where they are available to transport its passengers.

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Current issue status: Safety action pending

So despite conducting an exhaustive 2+year investigation the Hooded Canary only now considers the Angel Flight response/action to the initial identified safety issue as unsatisfactory and therefore requiring the issuing of a safety recommendation - yeah right. Note that the initial identified safety issue is also dated 13 August 2019 (see HERE) but given the Angel Flight response obviously that is not possible. 

Still reading but at this stage this report IMO is the biggest bureaucratic stitch up since the PelAir ditching and there will be definitely MTF...

Angel Flight's response to the ATSB report:

ANGEL FLIGHT RESPONSE TO ATSB REPORT 13 august 2019

ANGEL FLIGHT IS AUSTRALIA’S LARGEST AND LONGEST-SERVING CHARITY FACILITATING COMMUNITY BENEFIT FLYING

Angel Flight has co-ordinated free flights for more than 100,000 disadvantaged rural Australians, whose only other option to attend city hospitals for specialist treatment is ground transport – often taking days each way, at times with the driver/ patients being very elderly or accompanying very young children, on dangerous outback roads. These people cannot afford commercial air travel, which is more often than not, unavailable from their hometowns. Angel Flight recognises, publicly and privately with the affected people, the consequences of tragic fatal accidents, wherever and in whatever circumstances they occur, and is (and has always been) committed to safety and welfare as its priority.

THE ATSB REPORT INTO THE ACCIDENT AT MT GAMBIER ON 20 JUNE 2017

RECOMMENDATIONS

The ATSB offered no safety recommendations to pilots flying light aircraft in bad weather.

The safety recommendation made was for the charity to book people on airlines for travel: this does not adequately factor in cost (particularly where two or more people are travelling, which is often the case); nor does it properly factor in the infrequent scheduling or non-existence of airline flights into country regions across Australia; the
inconvenience and difficulties faced by the elderly and families with young children at major city airports, and the associated ground travel; and appears to work on the assumption that city specialists and hospitals will gear their appointment times around airline timetables. Angel Flight does use airline flights where practicable and necessary, and will continue to utilise these services.

The rules implemented by CASA were not directed to the cause of the 2017 accident, or any other accident in the community benefit sector, and the ATSB has not given any support for those rules, save and except for that requiring pilots to write community benefit flights up in their log books, and note that fact on flight plans: the only flow-on from those rules is one of policing data – the very same data has been given by the charity to the ATSB.

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: it would have been of benefit to the flying community had the ATSB focussed on these aspects of the accident.

The safety message raised – induction training and safety management systems, together with a pilot mentoring programme, had already been implemented by the charity prior to the ATSB report and recommendations. Angel Flight takes, and has taken, a very serious and proactive approach to improving safety, and will continue to do so. Angel Flight will continue to urge CASA to improve its Human Factors training in the pre-licencing stage of training, in addition to the refresher courses now offered.

THE DATA

The charity engaged two senior expert statisticians and an analyst, all of whom concluded that the accident rate was not significantly different from the rate for other private flying across Australia.  The ATSB also chose to compare only the passenger-carrying sectors of flights coordinated by the charity –it disregarded the flights, also coordinated by the charity, where the aircraft flew from home base to the city collection points, the return trips back to base, and the positioning flights to collect passengers from their own home towns: it did, however, include those flights when reporting ‘occurrences’ against the charity flights. There was, and is, no reason for this failure. To
remove up to two-thirds of the coordinated flights in order to make statistical conclusions is unjustifiable. Moreover, when comparing the data with private flights generally, it did not exclude the non-passenger flights for that group – all flights were counted in the general private sector, but not in the charity sector.

Angel Flight has coordinated more than 46,000 flights for the purpose of travelling to, returning from and carrying rural Australians to the city for non-emergency medical appointments. The ATSB has excluded more than half of these flights when assessing accident rates, with the result being to substantially increase the alleged statistical accident rates.

THE EXACERBATION OF THE DATA ERRORS

The ATSB has not adopted its own protocols (and those followed in the US) of counting flight hours for general aviation accidents - instead it counted only flight numbers. An example of that methodology, further invalidating the findings, is (a common route), where the pilot departs home base in Tyabb, flies to Essendon to collect passengers, flies from Essendon to Hay, then returns to Tyabb (three sectors) – this is counted as one flight by the ATSB for its statistical purposes. The flight time for this route in a Cessna 182 would be at least 3.5 hours yet the ATSB gives it is given the same status as a 6-minute touch-and-go circuit at Essendon. To disregard both the actual flight numbers, and the flight hours, compounds the errors (and unreliability) of the findings to an extraordinary degree.

OCCURRENCES

The ATSB also looked at ‘Occurrences’ in controlled airspace (in comparison with private flights generally, most of which occur in uncontrolled space, and therefore are not reported). The ATSB acknowledged that they have no data from flights OCTA, so they did not take that fact into account.  The investigators also included in the occurrence data (adverse to the charity), instances where the admitted and conclusive report findings included ATC errors; errors of other aircraft causing safety breaches (not the fault of the charity flight); the proper reporting by the charity-organised flights where others had caused danger (including, for example, a pilot reporting a model aircraft illegally
on a flight path, causing the authorised charity aircraft to take evasive action: this was included as a ‘negative’ occurrence against the charity; and diversions to other airports in the interests of safety.

This cannot be regarded as valid in the collection of statistical data, and nor was it found to be so by the experts.

OTHER FINDINGS

The ATSB, amongst its findings, noted that Angel Flight was planning a mentoring program: this is incorrect, and known to the ATSB – the charity implemented its pilot mentoring programme more than a year ago. It was required to stop because CASA introduced rules which imposed restrictions on who could accompany a pilot, as was made very clear by the written advice of a senior CASA executive that “another pilot can accompany a pilot on a CSF as operating crew, so long as the other pilot qualifies to be a co-pilot of the aircraft and has such duties in relation to the CSF”: this clearly precludes pilots from being on board for mentoring, familiarisation, and observation of Angel Flight’s processes and safety culture.

FUTHER OVERLOOKED FACTS

It has not been acknowledged that all volunteers operating their own (CASA-approved and maintained) aircraft for the purpose of these community benefit flights, are CASA-licensed, CASA trained, and CASA-tested on a one or two-yearly basis. Angel Flight has ensured that the volunteer pilot qualifications are not less than as permitted by the Civil Aviation Safety Regulations, and for the entire period leading to the investigation (14 years), these pilots have had substantially more than the required experience for passenger-carrying private flights in Australia. The new Rules decreed by CASA would have had no bearing on the accident under investigation, and this has been acknowledged by CASA. The pilot under investigation had greater experience than that required by either the former or the current Rules.

Angel Flight has been urging CASA for a substantial time, to re-visit and strengthen the training of its pilots in the human factors area prior to issuing licences. With the additional safety, risk management and induction training that Angel Flight has already implemented, the addition of CASA training would be beneficial for all pilots in this and other general aviation environments.

This message has been authorised by Angel Flight Australia.

And from Sandy off FB...

Sandy Reith The independent corporate body. ATSB, divorced from proper Ministerial control in 2009 by then Minister Albanese, has shown again it’s incompetence by slinging around opinions which are completely unsubstantiated. It’s safety comparison by category of flight, same ridiculous comparison as made out by CASA, it’s bedfellow and leader.

Elsewhere those with professional knowledge of statistics all say that the tiny number of accidents makes such claims null and void. If ATSB was going to have any semblance of balance it would also point to the extraordinary mess that CASA has made of the rules, which contribute hugely to the lack of IFR rating uptake by private pilots. By CASA inappropriately instigating the Cessna Supplementary Inspection Documents for privately operated aircraft, and other unnecessary and expensive imposts throughout General Aviation, all contribute to failings.

Not to mention the decline in flying training, including loss of experienced instructors, due the near impossible and super expensive rules relating to training which have sunk hundreds of flying schools so that Instrument training is now confined mainly to the capital cities.

The independent corporate body is a model of governance that cannot work properly in the National interest because it’s incentives are only to look after itself. Human nature will prevail and none of these bodies will ever do their proper job until back where they belong, directly under a Minister. 

TICK..TOCK minister TICK..TOCK indeed -   

MTF...P2