[Peetwo]

ATSB inquiry update: Angel Flight submissions.

Via the inquiry webpage:

8 Angel Flight - ATSB (PDF 4695 KB) 

ATSB REPORT A0-2017-069: ANGEL FLIGHT OVERVIEW


Angel Flight has been looking forward to this report for more than two years, hoping that it would
help to identify all of the factors that contributed to the accident and provide some constructive
guidance on how to reduce the risk of another similar event. Unfortunately, what we have is not
a comprehensive analysis of the accident but a detailed investigation of Angel Flight that uses
biased statistics to paint Angel Flight as an inherently unsafe organization.

There are numerous deficiencies in the ATSB statistical analyses that have led to incorrect conclusions
about both accident rates and occurrence rates. A critical aspect of any statist ical analysis is
ensuring data sets are properly matched, and this is where the report is most deficient.

Overview

It is obvious to any reasonable person that the accident was the result of the pilot taking off in
weather for which he was neither qualified nor competent. However, there appears to be no
investigation of the factors that may have led to his decisions, apart from an unjustified
assumption of operational deficiencies within Angel Flight....

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9 Angel Flight - CASA (PDF 1697 KB) 

ANGEL FLIGHT AUSTRALIA OVERVIEW STATEMENT RE CASA LEGISLATIVE INSTRUMENT 09/19 FOR

SUBMISSION TO SENATE INQUIRY

The entire process of introducing CASA 09/19 was unreasonable, poorly managed, delivered no
identified safety benefit, and contradicted most of the principles that underpin CASA's regulatory
philosophy - significantly, CASA has conceded that none of the Rules addressed, nor would have
prevented, any community service accident (or other identifiable accident):


1. Issuing the draft one week before Christmas and limiting the time for comments to the peak
January holiday season was totally unreasonable and minimised the opportunities for
feedback from the aviation and wider communities. None of the draft rules had been raised
noir discussed with Angel Flight, notwithstanding communications, meetings and
correspondence between Angel Flight and CASA (on a voluntary basis), and inviting CASA to
Angel Flight offices to observe all processes and view all documents. The hastily-prepared
Rules were presented (orally - no written document was provided) to Angel Flight by Chris
Monahan on 28 November, the day after the ATSB had called to request advice from both
Angel Flight and CASA as to what actions had been taken since the June 2017 accident. When
at this time CASA (Monahan) was challenged about this, his response was to acknowledge
that the Rules as proposed did not have any relationship to the accidents, but that "we had to
do something". This conversation occurred at the Angel Flight office on 28 November 2018.

2. The draft of the Legislative Instrument was issued with undue and unprecedented haste, only
days after the closing date for submissions. CASA purported to rely upon the Consultation
Responses in formulating its Rules. This was highly selective and lacked transparency and
integrity - a single example will suffice to illustrate this:

Response 614317021 by experienced ATPl/Airline/Corporate Jet/Ught Aircraft (twin}
owner/operator {HP R .... ) is attached to this overview. The submitted response by the pilot
comprises 4xA4 pages typed in single-line spacing. The CASA- published submission did not
represent what the pilot wrote (and is also attached): the latter comprises only a single
paragraph, unrepresentative of the actual submission of this pilot. This has flowed on to
the ATSB - CEO Mr Greg Hood has (in a pre-publication meeting in Canberra on 19/8} stated
that he had read all of the submissions to CASA as part of his information.


3. The Instrument initially excluded helicopters although there was no safety reason for doing
so, and an amendment was hastily issued to rectify this deficiency. At no time had Angel Flight
(during any of the meetings with CASA nor in any correspondence) been given any notice of
the proposal to ban helicopters, and CASA was well aware that Angel Flight arranged volunteer
helicopter flights to remote locations, particularly in Queensland and NSW, during flood
events.


4. Contradictory statements were made about the definition of a community service flights. At
Senate Estimates, CASA agreed that positioning legs were also community service flights. Mr.
Monahan said "If you're going to be reimbursed by the CSF then, in that case, yes. It goes under
that construct.". All legs are co-ordinated, and fuel reimbursed, by Angel Flight. The only
possible explanation for reducing the flight numbers by more than half (and substantially
reducing flight hours) is to ensure a statistical justification for the Rules.


5. The limitations on passengers mean that, for example, a parent taking a child for medical
treatment could not take another child who did not have a medical condition, even when
there was no care available for the second child while the parent was absent. When this was
questioned, the response was "It is CASA's understanding that CSF are scheduled in advance,
often by several weeks which should give sufficient time for families to make any necessary
arrangements, such as for those who cannot accompany the patient on on CSF''. Clearly, the
author (CASA's Chris Monahan), has little appreciation of the limited services available in rural
areas. The advice to pilots on the CASA web site is now "The decision on whether the carriage
of ..... a support person or persons chosen by the patient is considered necessary to provide the
required support or assistance is a matter for the reasonable judgement of the pilot-incommand".


It is unlikely that CASA has jurisdiction to impose upon a pilot the requirement to
assess the emotional or psychological state of a passenger for this purpose, and nor should
that be the responsibility of a pilot.


6. The same limitation on passengers meant that Angel Flight could not continue its pilot
mentoring program. CASA initially advised that a second pilot could be carried only "so long
as the other pilot qualifies to be a co-pilot of the aircraft and has such duties in relation to the
CSF''. That statement differs from the current advice on the CASA web site, which now permits
carrying additional operating crew. "The decision on whether the carriage of operating crew
.... is a matter for the reasonable judgement of the pilot-in-command in exercising their
responsibiflties, under regulation 224 of CAR, to ensure the safety of the aircraft, persons and
cargo carried on the aircraft." The mentoring programme implemented at the initiative of
Angel Flight was lauded by CASA at the time. Clearly the observation by a new volunteer pilot,
of the processes, safety culture, and operation of the charity is beneficial - and was never
intended to be a co-pilot or technical training role. There is no plausible explanation for the
curtailing of this mentoring initiative.

7. One of CASA's stated principles is that "CASA will adopt a regulatory approach based on a
sound assessment of the level of risk associated with particular aviation operations."

However, the risk analysis employed in justifying the Instrument was totally invalid. CASA
claimed at Senate Estimates that" it is four or five times less safe to fly with Angel Flight
than it is to fly with your mate". That claim was based on data obtained from the BITRE
annual survey of general aviation activity. However:

• It is individual aircraft owners, not Angel Flight, who report aircraft usage to BITRE and,
for most owners, it is difficult, often impossible, to determine the aircraft hours used in
community service flights because is no way of recording the purpose of a flight in the
aircraft log book.

• BITRE has requested data on community service flights only since 2014 and their records
show an average of only 46 aircraft reported CSF activity each year, with average annual
flying hours of 1775. The figures for Angel Flight in the corresponding period are 207
aircraft and 3111 hours. It would be impossible to extrapolate the four years of BITRE
data to 10 years and expect to have reliable data, as CASA claimed. And these figures did
not take into account any other community service or 'fun flight' operation, and nor was
there any matching definition of what constituted a community service flight, in the BITRE
surveys. It has been admitted by the ATSB that the BITRE data is further unreliable
because the survey is not completed by all pilots - and the non-compliance rate is high.

• BITRE define community service flights as "flights provided on a voluntary basis for public
benefit", a broader definition than now applied by CASA and one which would include not
only Angel Flight but Little Wings, Wings4Kidz, Funflight, flights for Cancer Kids and
various local events organized by aero clubs and other organisations.

8. The DAS has previously stated (Ref.: CASA Briefing June 2018) that "In aviation, we don't need
more rules - we probably need fewer", yet this Instrument introduced more regulation with
no demonstrated safety benefit.

9. The Instrument is contrary to the "Statement of Expectations for the Board of the Civil Aviation
Safety Authority" published 15 April 2015 that requires CASA to consider the economic and
cost impact on individuals, businesses and the community in the development and finalisation
of new or amended regulatory changes. There is no evidence that the possible increase in
maintenance costs for owners using CASA Schedule 5 were considered.

10. CASA's approach to this matter is also contrary to both the spirit and the letter of the
Australian Government Guide to Regulation (Commonwealth of Australia, Department of the
Prime Minister and Cabinet, 2014). That guide makes clear that non-regulatory alternatives
must be properly considered and that safety benefits need to be quantified - not just
subjective.

11. CASA's approach to this matter is also contrary to the recommendations of The Aviation Safety
Regulatory Review (ASSR), which recommended that the principles of future rule
development should:

•  adhere as closely as possible to the substance of rules in other developed jurisdictions
  

(US, New Zealand, Europe, and Canada) to ensure compatibility, facilitating bilateral
recognition agreements and efficient international operations; and

• include unique Australian provisions only when absolutely necessary, and only when
  

the Steering Commitee formally agrees to their inclusion.

12. During the course of a meeting 11 January 2019, in Canberra between Angel Flight CEO
Marjorie Pagani, Angel Flight Director Bruce Sackson, Shane Carmody, Chris Monahan and
senior executive staff, Mr Carmody was challenged (by Angel Flight CEO) as to why CASA
had chosen to by-pass the usual protocols for regulatory reform. Mr Carmody responded
firstly with "I have the power", and when challenged further on this issue, responded with
''because it's easy".

However, the fundamental deficiency with the Instrument is that none of the additional rules would
have prevented, or even reduced the potential for, the only two Angel Flight fatal accidents (Nhill and
Mt. Gambier) that have occurred more than 16 years. In both cases, the pilots and aircraft involved
met or exceeded all of the new requirements. Mr Monahan conceded this at a meeting with Angel
Flight CEO Marjorie Pagani in the offices of Angel Flight, on 28 November 2018 and subsequently has
reaffirmed this in answers to the Senate Estimates Committee.

Angel Flight has consistently implored CASA to revisit the training for pilots in respect of Human
Factors, Threat and Error Management, and Weather-related incidents, prior to the issue of licences.
This has been ignored. CASA has added to its post-licence seminar program some additional human
factors modules, but nothing has been done to address the cause of these accidents, or any of the
many VFR into IMC events which occur annually in Australia.

The value of the Legislative Instrument is accurately reflected in a recent letter to the editor of
Australian Flying (September - October 2019), unrelated to either Angel Flight or the Legislative
Instrument, which says "Instead of changing the rules, CASA should concentrate on why pilots
bend the rules or do not understand the consequences of their actions" and further that "Changing
the rules will have little impact on pilot behavior".

Now why does 8 thru 12 sound oh so familiar...
Hmm...ah yes now I remember - 
Ref: CASA embuggerance of APTA & GB update

..initiated a process in October 2018. That process was a complete reversal of previous CASA policy. It came instantly, and with absolutely no warning. The entire process could have been avoided had CASA decided to inform me or meet with me. The associated impact on my business and the gross waste of taxpayer funds achieving that objective, has been truly disgraceful and unacceptable. My experiences may be shared by others in Industry, and if so, it requires a Royal Commission, it really does.


Those actions and decisions

• Were in clear breach of almost every element of CASAs own Regulatory Philosophy.
• In breach of the PGPA Act which requires these personnel to use public funds and resources responsibly.
• Breach the requirements of Administrative Law, Procedural Fairness, and Natural Justice.
• Were quite simply. Not well intentioned, and certainly not based on safety considerations.
• Bullying and Intimidating in their nature.
• Cannot be supported by any clear or concise legislation, and that is a requirement placed on CASA...(for more refer to above link)

 
MTF...P2 

Ps On P7 post, the Disallowance Motion(s) is up for debate on Thursday: 

Thursday, 19 September


To be moved by Senator Patrick:

• Civil Aviation (Community Service Flights –Conditions on Flight Crew Licences) Amendment Instrument 2019 [F2019L00554]; and
  
  
• Civil Aviation (Community Service Flights -Conditions on Flight Crew Licences) Instrument 2019 [F2019L00134].