[Peetwo]

Vic Coroner scathing of RAOz?? - 

Courtesy the other Aunty:

Coroner says licence should not have been issued to pilot who crashed

 
Mathew Farrell died in a plane crash in Victoria's High Country. (Supplied: Maurice Blackburn)
In short: 
In short: 
Findings of an inquest into the death of Mathew Farrell, who died in a light aircraft crash in Victoria's high country, have been handed down.
The inquest was prolonged after correspondence was presented showing senior members of Recreational Aviation Australia (RAAus) had concerns about Mr Farrell's certification just weeks after his death.

What's next?
The coroner has recommended the Civil Aviatian Safety Authory review the conduct of Recreational Aviation Australia officers during the investigation and inquest.

A Victorian coroner has ruled a pilot who died in a crash in Victoria's High Country should never have received his licence with his limited flying experience.

Cinematographer, adventurer and environmentalist, Matthew Farrell, was 42 when he died in a light sport aircraft crash at Lucyvale in north-eastern Victoria on September 18, 2022.

Mr Farrell was airborne for about 40 minutes before crashing amid poor weather conditions.

A keen paraglider who lived in Tawonga, Mr Farrell obtained his recreational pilot's certificate in April 2022 through accelerated pathway training which recognised his existing paragliding experience.

In his findings, Coroner Paul Lawrie also referred the conduct of Recreational Aviation Australia (RAAus) officers to the Victorian Director of Public Prosecutions.

He said Mr Farrell should never have been granted his licence and had not completed the requisite amount of flying time due to his accelerated pathway.

Mr Farrell clocked 9.8 hours of flight time over four flights.

It was less than the 20 hours of dual-command and five hours of pilot-in-command flying hours normally required.

"In my view the documents, including Mr Schaefer's diary notes, are sufficiently clear on their face to reveal the true nature and timing of the turmoil within RAAus concerning the validity of Mr Farrell's [recreational pilot's certificate] and cross-country endorsement," Mr Lawrie said.

He said Mr Farrell had a confident personality.

"The sad reality was he was over-confident," he said.


A career working with cameras took Mathew Farrell around the world.  (Supplied: Brad Harris)

A six-day inquest into Mr Farrell's death was held in January and February 2024, before the coroner handed down his findings in February 2025.

Unseen documents

As part of his findings, Mr Lawrie made five recommendations including that the Civil Aviation Safety Authority (CASA) review the conduct of RAAus during the investigation and inquest.

RAAus is Australia's largest administrator of pilots, maintainers and aircraft.

It was the body that granted Mr Farrell's licence.

During the coronial inquest into Mr Farrell's death, lawyers representing Mr Farrell's fiancee, Karen Waller, brought forward previously unseen documents that showed concerns about whether he should have been licensed.

They included an email from then Recreation Aviation Australia (RAAus) Head of Flight Operations, Jillian Bailey, who disclosed to then chief executive Matthew Bouttel she was concerned about Mr Farrell's licensing.

The court heard Ms Bailey was investigating the accident and had attended the scene and discovered later that she issued a license to Mr Farrell in contravention of the requirements of the RAAus operations manual.


Mathew Farrell with his partner Karen Waller. (Supplied: Karen Waller)

The court had heard Ms Bailey was stood down from her role for one week because of her disclosure.

It came while she was also playing a role investigating the crash, but the potential conflict of roles was never disclosed.

"I'm satisfied that RAAus has acted unreasonably in the lead-up to the inquest, and during the inquest itself," Mr Lawrie said.

"There is no doubt that it should have disclosed the [critical documents and exhibits]."

Other findings

Mr Lawrie repeatedly said that paragliding experience could not be a suitable replacement for time flying a motorised aeroplane.

He recommended that CASA amend its Flight Operations Manual to clarify the aeronautical experience that constituted "recognised flight time" according to each type of aircraft, and to clarify the experience required for licence endorsements.

He also recommended that CASA amend its manual to redefine what it considered an aeroplane.

Mr Lawrie recommended that the Australian Transport Safety Bureau (ATSB) should investigate all fatal accidents with RAAus-registered aircraft, rather than RAAus.


Mathew Farrell and Karen Waller enjoyed outdoor adventures. (Supplied: Maurice Blackburn)

He said it was no longer tenable to leave investigations to other organisations and urged the ATSB take more of an active role in fatal lighter aircraft crashes.

The determination came after RAAus said it would no longer investigate fatal accidents of its own aircraft.

Mr Lawrie also recommended that RAAus develop standardised training records for flight instructors that allowed for detailed auditing of training in a form approved by CASA that must be used by flight instructors in all instances.

Dreams cut short
Ms Waller and her legal team from Maurice Blackburn Lawyers welcomed the findings of the coroner.

"Mathew Farrell was a talented filmmaker and photographer," a statement from the lawyers said.

"He was a wonderful partner to Karen and they had plans to build a life together.

"Sadly their dreams were cut short by this tragic incident."

The joint statement went onto say inquest's findings had confirmed concerns of Ms Waller and her lawyers from the beginning of investigations.

It said they would be considering further legal action.

"The coroner has found that the flight training delivered to Mathew was so compressed that its efficacy must have been significantly compromised," the statement reads.

"Karen's hope was that the inquest would be a transparent and thorough inquiry into the circumstances that contributed to Mathew's death.

"We have been troubled by the obstacles that have been put in the way of that during the inquest, this is evident by the findings which have been delivered today.

"It is alarming to hear the coroner conclude that RAAus had engaged in a deliberate strategy to hide key documents from the court in relation to an investigation into a death of one of their own members."

Plus from Oz Flying:

]Coroner targets RAAus in Lucyvale Findings

17 February 2025



Victorian Coroner Paul Lawrie has referred key people at Recreational Aviation Australia to the Victorian Director of Public Prosecutions after finding the organisation hid key issues from a coronial inquest.

The move came as the coroner handed down his findings last Friday into the death of pilot Mathew Farrell in the crash of a Jabiru near Lucyvale, Victoria, in September 2022.

Farrell was attempting to fly from Mount Beauty to Shellharbour in NSW when the aircraft crashed into terrain. The coroner found that Farrell had flown into instrument meteorological conditions and likely lost control due to spatial disorientation.

Central to the inquiry was the standard to which the pilot had been trained and RAAus' decision to award him a Recreational Pilot Certificate (RPC) based partly on previous aeronautical experience flying paragliders.

Critically, the coroner found also that RAAus had their own misgivings about the decision to issue the RPC even though the evidence given to the court contradicted that. The coroner said the organisation had employed a deliberate strategy to hide key issues.

According to the coroner's published findings, then Head of Flight Operations Jill Bailey gave evidence to the court that Farrell's RPC was validly issued using the converting pilot pathway, that human factors and cross-country endorsements were also validly issued and that the issue of the RPC was never in dispute.

However, subsequent documents initially not supplied to the court showed that Bailey had e-mailed then RAAus CEO Matt Bouttell after the crash with her own concerns that issuing Farrell's RPC may have contravened RAAus' own operations manual.

Bailey was then placed on a week's Special Leave.

The coroner found that RAAus' had counted paragliding hours towards the minimum required for an RPC even though the operations manual states qualifying hours need to be in an "aeroplane", a definition that doesn't cover paragliders.

"The documents discovered in the further investigation clearly reveal that key aspects of Ms Bailey’s evidence were false," the coroner stated. "In fact, she had held serious concerns about the validity of the issue of Mr Farrell’s RPC as a converting pilot and the validity of his cross-country endorsement – to the extent that the issue was the reason she was placed on a period of Special Leave ...

"I am compelled to conclude that RAAus engaged in a deliberate strategy to hide these key issues from the court. Ms Bailey gave evidence which was false in material respects, which also served to hide key issues."

Evidence was also uncovered that showed Iain Clarke, Safety Manager of the Sports Aviation Federation of Australia (SAFA), sent an e-mail to Bailey in the days after the crash that expressed misgivings about Farrell, particularly in Farrell's approach to risk and recognising his own errors of judgement.

This lead to coroner Paul Lawrie believing that "In pursuing his RPC, Mr Farrell was entering into a realm of aviation vastly different to that of a paraglider pilot. It required a new suite of knowledge and technical skills such that Mr Farrell's paragliding experience offered only a very limited advantage. It was certainly no place for an over-confident novice pilot."

The coroner also stated that Farrell's instructor, the late Geoff Wood, "should have recognised this and sought to imbue his student with a healthy degree of humility – to be aware of his limitations and his very limited experience flying a powered aircraft."

Additionally, the coroner found that the ATSB's policy of not investigating RAAus' accidents needed to be reviewed because when RAAus withdrew from the Lucyvale investigation citing a conflict of interest, Victoria Police, which does not have specialist aviation accident investigators, became the lead agency.

"The conduct of RAAus in this case, and its withdrawal from the investigation of fatal accidents should compel a change in the ATSB's policy," the coroner suggested.

The coroner also turned the spotlight on CASA, suggesting the regulator needed to prompt a review of RAAus' flight operations manual to clarify recognised flight time for certificates and endorsements, and the definition of "aeroplane" be bought into line with the CASRs.

After the coroner's referral, it will be up to the Victorian Department of Public Prosecutions to review the evidence to determine what charges,
if any, are to be laid against RAAus staff, and if there is a reasonable prospect of getting convictions.

It is not mandatory for CASA, the ATSB or RAAus to comply with findings and recommendations arising from coronial inquests.
RAAus has been contacted for comment.

MTF...P2