[Peetwo]

Mangalore inquest and Vic Coroner Aviation inquests? - 

Via this week's SBG and the UP:  "..Accident investigation descended into little more than a PR exercise, all to promote Popinjay from his level of incompetence to new heights.."

ER_BN

Advance,

Thank you! If you posted a link (underlined), I could not access it. May be my ongoing and increasing dementia.

However the coroner’s office has been very helpful and I believe there is a weblink available for people not able to attend in person. One can watch it just like Senate Estimates, not that I’ll be using it and it does raise some issues…

I’ve been assured the inquest is open to the general public, not that I have a “seat” at the table, it will be a case of quiet observation whilst there and reflection after each day.

Just like Global Warming, I am not optimistic about this inquest but I still have hope, if only for the relatives of the four pilots and also for the air traffic controller. My analysis would indicate those desires are not mutually exclusive…

I expect that hope to be extinguished after the inquest. I expect it to be another VH-TNP / Benalla.

The ATSB report in my opinion is full of omissions and misinformation. I am not suggesting a conspiracy, merely (like a lot of things in Australia) severely flawed by a combination of seeming incompetence, mediocrity and self interest. I cannot see any other reason for the strange content and simplistic conclusions.

The only good news is that the inquest has been given the varsity i.e. Justice John Cain, the Chief Coroner of Victoria.

However, if the right witnesses aren’t called and the right questions aren’t asked coupled with accurate physical evidence; it doesn’t matter how good the intentions are “…the road to hell is paved….” etc.

As far as I’m concerned were FS still in place the accident would not have happened. That in itself is a sad indictment of the “advancement” of policy in regard to aviation safety specifically to airspace in Australia below 10,000 ft since the early 1990s. Technology and surveillance are not always “an advancement” especially in the transition from humans to automation.

I am not sure having a front row seat was a good idea and was in fact really just a “poisoned” chalice.

Sigh!

With a quick search across the Vic Coroner website, I was able to find the following for next week's scheduled inquest hearings: https://coronerscourt.vic.gov.au/inquest...t-hearings

Name Mangalore Aircraft Accident

10:00am
Location Southbank Court 1
65 Kavanagh Street, Southbank VIC 3006
Ph : 1300 309 519
Fax : 1300 546 989
Court reference number COR 2020 0950, COR 2020 0971, COR 2020 0951 & COR 2020 0976
Coroner State Coroner Judge John Cain
Case Type Inquest

(Listed for Monday 25th through to Thursday 28th)

While trolling the Vic Coroner website, I came across the Coroner's inquest findings for other Aviation accidents, including one, that took me completely by surprise, listed as the 'Essendon Plane Accident'??

Ref: https://coronerscourt.vic.gov.au/sites/d...cident.pdf

This report was apparently delivered on the 30 September 2022. Whether or not it was publicly available from that date - who knows? I certainly can't recall there being any MSM press coverage in regards the findings?

One thing that is obvious from reading the report, is that the splintering off of the bollocks Essendon DFO Approval Process investigation, with the final report being published 30 June 2023, was a Hood masterstroke as there was not one reference to the DFO building as being a factor causal to the accident. JOB DONE - the PILOT DONE IT! 

For further proof of the pilot being completely stitched up, with CASA being a perfect model litigant and a responsible (but not liable) Federal government safety regulator see - HERE - for the legal WWC (Weasel worded confection) in reply to the CASA addressed Coroner recommendations..    

There is also an interesting (same theme -   ) CASA LSD reply for the recommendations that came from the 'Barwon Heads Accident': https://coronerscourt.vic.gov.au/sites/d...LINN_1.pdf

Dear Registrar,

Investigation into the deaths of Donald Hateley, Ian Chamberlain, Dianne Bradley and
Daniel Flinn - Barwon Heads Aircraft Crash

We refer to Coroner Jamieson’s findings dated 11 February 2020 and the two
recommendations directed to the attention of the Civil Aviation Safety Authority (CASA).

At the outset, CASA sincerely apologises for the delay in responding to the recommendations
which occurred due to an administrative oversight.

In respect of the two recommendations, the following responses are provided:

Recommendation 1 – that CASA mandate the use of SARTIME for all Visual Flight Rules
flights over water

1. Upon reviewing the Coroner’s findings, we note that CASA already has requirements
in place for the nomination of a search and rescue time (SARTIME) for visual flight
rules (VFR) flights over water.

2. As noted in the findings (see [123] – [126] of the Background Circumstances and [7]
of the Comments), pilots conducting VFR flights over water are already required to
submit a SARTIME flight notification to Airservices Australia or leave a flight note with
a responsible person. This is by force of regulations 240 and 241 of the Civil Aviation
Regulations 1988 (CAR) and paragraph 1.10 of the Aeronautical Information
Publication (AIP) En Route Supplement Australia.

3. If the focus and intent of the recommendation is that CASA require the use of
SARTIME only and not allow the leaving of a flight note for VFR flights over water,
then CASA confirms that the recommendation will be taken into consideration as part
of the ongoing regulatory development activities referred to further below.

4. Of particular relevance to this recommendation is that, following extensive
development and community consultation over a number of years, new regulations
contained in Part 91 of the Civil Aviation Safety Regulations 1998 (CASR) for the
conduct of flight operations will come into force on 2 December 2021. These
regulations will cover VFR flights over water and flight monitoring rules including
SARTIME requirements. In particular, Division 91.D.3 provides for flight notifications
as follows: (read for the CASR references etc)

Recommendation 2 – that CASA increase IFR training and recency requirements for
PPL candidates and holders, for the purpose of, but not necessarily limited to, further
education for candidates on the fatal dangers of inadvertent entry into IMC

8. At the outset, we draw to attention concerns as to references to instrument flight rules
(IFR) training in relation to private pilot licence (PPL) holders. IFR training is not
mandatory for PPL holders and references of this kind have the potential to confuse.

9. Candidates for and holders of PPLs who operate in Visual Meteorological Conditions
(VMC), being the majority of PPL holders, are not required to complete IFR training
and there is no recency requirement. However, these pilots are required to
demonstrate basic instrument flying competency as a candidate for and ongoing
holder of that licence. The assessable standards are consistent with the international
licensing standards and have been in place for many years.

10. CASA is generally satisfied that the aeronautical knowledge standards and the basic
training for instrument flying, as opposed to specific training for IFR operations, are
currently appropriate. Assessment of basic instrument flying competency is also
included as part of the mandatory biennial flight review standards for PPL holders.

11. Candidates for a PPL are also taught of the serious risks of inadvertent entry into
instrument meteorological conditions (IMC) as part of the aeronautical knowledge
standards and practical flight competencies which they must be able to demonstrate
(including via theoretical and practical examination) prior to the issue of a PPL. These
standards and competencies are set out in the Manual of Standards issued to support
Part 61 of the CASR.

12. In addition, CASA provides many safety education products including seminars and
materials such as the magazine, Flight Safety Australia, which regularly deal with the
topic of inadvertent entry into IMC. For example, a recent article in Flight Safety
Australia titled “Weather to fly” dealt with these issues. This article can be accessed at
Weather to fly . Examples of the kinds of relevant material routinely addressed at
aviation safety seminars can be accessed as “Enhancing pilot skills – expect the
unexpected“.

13. To the extent that the recommendation is targeted at CASA increasing IFR training
and recency requirements, CASA notes that IFR training, by its nature, is designed to
teach the skills necessary for pilots to safely fly by reference to instruments only. It
does not form part of the general PPL syllabus of training as it is an additional skill
and separate rating for flying operations conducted under the IFR. CASA considers
that the training presently provided to PPL pilots around the need to ensure they stay
in VFR conditions is adequate and that more specific IFR training is only necessary
for pilots who wish to operate under the IFR.

14. CASA considers that training for inadvertent entry into IMC is more appropriate for
pilots rated only for VFR conditions. Without appropriate prior training and an aircraft
designed for IFR operations, such pilots are more likely to become spatially
disoriented or unable to safely operate the aircraft in IMC.

15. Therefore, while it does not propose to take any action in relation to this
recommendation at this stage, CASA is proposing a review of the competency
standards and the two-yearly review of proficiency rules (known as a flight review) for
private pilots in the next 18 months. A review of the basic instrument flying standards
and the related non-technical skills and human factors required of PPL holders will be
included in that review.

Please contact the writer should you require further information or should you have any
further enquiries concerning this matter.

Yours sincerely,


Anthony Carter
Special Counsel
Litigation, Investigations
and Enforcement Branch

Ph: (02) 6217 1151
Fax: (02) 6217 1607

Email: anthony.carter@casa.gov.au

Also of interest from the Coroner Findings for Aviation was a response from the Department of Infrastructure, Regional Development and Cities and the Australian Transport Safety Bureau in reply to recommendations issued to the ATSB in the context of a 13 March 2016 double fatal microlight trike accident at Yarrawonga (Note the signatories -  )





(For the combined Vic Coroner Aviation accident reviews and inquest findings listed see - HERE)

MTF...P2 

[Peetwo]

Mangalore midair Coroner inquest update?? - 

Via the SMH:

Inquest probes why no safety alert was sent to pilots before planes collided

Erin Pearson
March 25, 2024 — 5.50pm

In the two minutes before two small aircraft collided midair in the first crash of its kind in Victoria, an air traffic controller monitoring the airspace received two alerts about their trajectories.

Each time, he silenced the alert.


The aftermath of the fatal collision between two planes in Mangalore in February 2020.

At the time, proximity alerts – activated when planes are forecast to come within a certain distance of each other – were a frequent occurrence in the busy non-controlled airspace near Mangalore Airport in central Victoria.

Air traffic controller John Tucker said the alerts were so common that he believed more than half were false or nuisance alerts, and that it was common practice for staff to silence the sounds.

But less than a minute after he silenced the second alert, two training flights collided eight kilometres south of Mangalore Airport.

Pilots Ido Segev, 30, Peter Phillips, 47, Christiaan Gobel, 79, and Pasinee Meeseang, 27, were killed in the collision at 11.24am on February 19, 2020.

It was the first midair collision between civil aircraft operating under the instrument flight rules and procedures – where pilots cannot rely on visual cues – in a non-controlled airspace, according to the Australian Transport Safety Bureau.

On Monday, Tucker, employed by Air Services Australia, told the first day of the inquest into the deaths that he believed warning alerts he was getting about the two aircraft in the minutes before they crashed were nuisance alerts that didn’t require a response.

He told the Coroners Court he had alerted each aircraft about the other after Meeseang signalled that she and Gobel were about to take off from Mangalore Airport as Segev and Phillips approached.

Tucker said the rules stated it was up to the two planes to communicate with each other to maintain a safe passover.



But the inquest heard both planes continued on their trajectories: Gobel and Meeseang ascended as Segev and Phillips descended.

The pilots’ final radio transmissions were played to the inquest as family members sat in court.

Tucker, an experienced air traffic controller who oversaw the airspace above Mangalore on the day, said by the time the final warning siren rang out in his office, it was too late to issue a safety alert as he believed it would only distract the pilots.

In his statement, he said he believed both aircraft had levelled off about 1000 feet (about 300 metres) apart and there was no risk of collision.

Soon after, Tucker said he noticed both aircraft had disappeared off his screen, and when he tried to contact them, there was no response.

On Monday, he acknowledged a post-incident report which suggested both aircraft were continuously climbing and descending in the minutes before the fatal crash.

“I made a judgment call which was not to issue a safety alert. At the same time I had to deal with other traffic at Wangaratta,” Tucker said.

“I expected the pair to be talking to each other.”


Air traffic controller John Tucker (right) outside the Coroners Court on Monday.CREDIT:CHRIS HOPKINS.

The coroner is investigating what led to the midair collision, who had what responsibilities on the day and whether collision warning technology should be mandated, among other things.

Outside the court, Segev’s fiancee, Brianna Sutcliffe, said the pair planned to marry in 2020 and have a family together. She vowed to fight for transparency about what happened given little is known about why the crash occurred.

“The extent of pain and suffering this has caused myself and Ido’s family is insurmountable and enduring. Not a moment goes by where I am not consumed by the traumatic events that surround his passing,” Sutcliffe said.


Brianna Sutcliffe, the fiancee of pilot Ido Segev.CREDIT:CHRIS HOPKINS

“Ido would have done anything for me, and now it is my turn to repay the favour. I will not rest until I receive transparency regarding the events surrounding the loss of my soulmate, Ido.”

Court documents released to the media show Meeseang was a Thai national who was in Australia to train as a commercial airline pilot. She was due to complete her instrument rating training on the day of the collision.

Phillips was the chief pilot at the Peninsula Aero Club.

The inquest continues.

MTF...P2 

[Kharon]

Coroners Court Vic. Barwon Heads -

Poor old Coroner; what a tangle. Recommendation #2 caught my attention.

Recommendation 2 – that CASA increase IFR training and recency requirements for PPL candidates and holders, for the purpose of, but not necessarily limited to, further education for candidates on the fatal dangers of inadvertent entry into IMC.

Aye, but: is that a 'real' solution?  The CASA response below defines the perennial problem, one which has never, globally, ever really been 'solved';. 

13. To the extent that the recommendation is targeted at CASA increasing IFR training and recency requirements, CASA notes that IFR training, by its nature, is designed to teach the skills necessary for pilots to safely fly by reference to instruments only. It does not form part of the general PPL syllabus of training as it is an additional skill and separate rating for flying operations conducted under the IFR.:-*CASA considers that the training presently provided to PPL pilots around the need to ensure they stay in VFR conditions is adequate and that more specific IFR training is only necessary for pilots who wish to operate under the IFR.*

That last sentence presents a clear, cut and dried stand point, which, in essence, is bang on the money; no argument. However; VFR pilots pushing on into Instrument conditions continues, world wide, to be a big number on the butchers bill. A solution is required and IMO it is not CASA's, FAA, CAA or any other 'authorities' job to stop the body count. Perspective is needed from the pilot body; that (IMO) is where the solution lays.

Both question and problem for the VFR pilot lays within the ever asked question -  'go' or; not go? - that is the question; ain't it?

“Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,etc...

Several ways to go toward a 'solution' which does not involve 'complex' regulation or outrageous costs. But 'brass tacks' first: if you were scheduled for heart surgery and your plumber turned up to do the job; or, if a power line fell across the garage roof, would you get a ladder from the shed, climb up and repair the break? What if there was a gas leak at home; would you try to fix it with a blow torch? Of course not; like fire fighting or Air Traffic control at Mascot - these are tasks which require dedicated training and a proven skill set. So why would anyone persist in flying into weather condition for which they neither have the training, demonstrated skills and experience to do the bloody job. Its balmy, statistically proven to be so and dangerous. 'Managing a flight, in real IFR weather is governed by some rules which are an unbreakable tenet  for survival; Lowest safe altitude; minima; ice management; fuel management; diversion; and the ability to draw the line; thus far and no further will I go.

The basic ability to execute a Rate 1 turn; on the clocks should be and was taught from the very first flying lesson; (well back in my day it was). Turn crosswind - set the turn angle by visual reference; then confirm - 80 IAS = 8+7 :: a Rate 1@15° angle of bank, ball in the middle - good job ; habit formed from first circuit. Basic escape from the insidious Bollocks of 'inadvertent'. There is NO inadvertent involved - none whatsoever.

One could lay some 'blame' at the feet of the BoM; they have a wide margin for error on a forecast. This works both ways; - for and against an outcome. It is quite possible to have to battle your way down to 'minima' and just 'squeak' in - legal on a reasonable forecast; and be equally worried along the journey about a forecast only to find an easy approach in the mildest of conditions. Such is the inexact science of computer generated models. BUT, that is what you have to work with. So then; what must we teach our VFR pilots?

Only my considered opinion and an insignificant one at best but; try I must.

Item 1 : ensure, from the beginning of 'training' that all in flight manoeuvres are initially set up by visual reference and confirmed by flight instruments; make it a life long habit, deeply entrenched.

Item 2 : Encourage 'students' to not just 'pass' the Met exam. Hell's bells' the BoM are only making educated 'guesses' and working with 'trend' models to forecast the weather and they all hold university degrees in the subject (well, mostly). Pilots (no matter the stamp) must; and I do stress 'must' be able to evaluate a 'forecast' and formulate a plan of action based on the worst case; particularly with regard to icing, turbulence and the effects of both wind and temperature on the terrain and flight path. Rule 1 - always - always - always have the 'back door' wide open. If trumps turn to crap - then at least; at the critical juncture; there is a viable, pre formulated 'escape' route (plan of action - just in case) available from the 'sticking points' noted along the flight path.

Item 3 : While I am a great believer in and frequent 'user' of Auto pilot and GPS systems; I am not certain that an 'early' dependency on such luxury items is a good thing in the early stages of training. Only my opinion; but there is a 'professional' need to be grounded in the real deal; hand flying in the bumps, awareness of the terrain, and understanding of where the weather is, where its likely to be better and where the 'trap' points are is an essential element. My grand kids can type 60 WPM - left handed on a 'screen' - but the notion of descending, over rising terrain, in cloud which is orthographically uplifting, while flying an aircraft is beyond their comprehension or learning.

For a complete diorama of the current shortcomings in pilot basic training - look no further than the BN2 event in Tasmania. No ones fault - but it does beg questions a Coroner has no chance of answering.

Here endeth the ramble, with apologies to the pureist and academics and law makers; but IMO the 'problem' begins (and ends) at grass root level; barring that there will always be 'them as what's gunna do-it' anyway. Those we cannot help.

Toot toot.

[Peetwo]

Red Rat the answer to all things on Oz Aviation Safety?? -   

Via the Oz:

Qantas to open new ‘safety academy’ in 2025 to teach other industries how to avoid disaster

Qantas is preparing to cash in on its solid safety record by lending its name to a new “safety academy” to be run in partnership with Griffith University and RMIT.

People seeking to enhance their safety credentials across a wide range of areas, including health, cyber, data and risk management will be able to pay to undertake a short course at the virtual academy from next year.

Qantas executive manager of group safety and health Ian Hosegood said the airline’s reputation as a safety leader was well known and the team looked forward to sharing that expertise in an increasingly safety-conscious world.

“I think it’s becoming more and more important that we maintain and develop the skills of safety professionals because there’s been an exponential change in some of the complexity,” Dr Hosegood said.

“With technological advances, with changes in regulation, and disruption into different industries, I think the pace of change is now much greater.”

He said Qantas personnel would be involved directly in the academy by providing mentorship and teaching, and developing materials with Griffith and RMIT.

“As we move into the later phases, we could have work placements in Qantas so people outside of Qantas would be able to come and have some integrated work learning within the Qantas environment,” Dr Hosegood said.

The establishment of the academy, which would offer online webinars in the first instance, would be funded by Qantas, Griffith and RMIT.

Courses – or micro credentials – would be paid for in much the same way as other university courses, with the cost expected to be within $500–$3500.

Credits from the courses would count towards other relevant postgraduate qualifications.

“This is not a cookie-cutter approach to safety science, but micro credentials with depth which offers a postgraduate learning environment for professionals who want to advance their careers and take the next step,” said Griffith Sciences Group dean Rosalind Archer.

RMIT Aviation Academy director Lea Vesic said the academy would help build a pipeline of safety leaders with a broad set of critical skills.

“RMIT’s partnership with Qantas is testament to the quality of our training and leadership – not just in producing job-ready graduates but fostering collaboration across the sector,” Ms Vesic said.

“These types of industry partnerships – and innovative training delivery – will be even more critical as we look to futureproof the aviation industry in Australia.”

Qantas also announced plans to invest $40m in a new ground training facility at its Mascot campus in Sydney, to keep its own people skilled in emergency procedures.

More than 5000 pilots and cabin crew were expected to be trained at the facility each year, once it opened in mid-2026.

Qantas chief executive Vanessa Hudson said that with more than 100 new aircraft on order for the airline and low-cost carrier Jetstar, the investment in training was vital.

“Each of those new aircraft represents a growth opportunity for our people and the broader industry,” Ms Hudson said.

“Our multimillion-dollar training investment means there will be new facilities and state-of-the-art equipment across Australia to train our current pilots and cabin crew, as well as the thousands of crew expected to join the Qantas Group over the next decade.”

Qantas already lends its name to a pilot training academy in Toowoomba and will open an engineering academy in Melbourne next year.

And courtesy of Lea Vesic, via LinkedIn...  

Lea Vesic 
The sky is not the limit, it is just the view. Executive MBA Candidate

1w • Edited •  1 week ago

Follow

? Exciting Announcement! ?
I am thrilled to announce the establishment of a new Safety Academy, a strategic partnership between Qantas, Griffith University, and our aviation team at RMIT Aviation Academy. This collaboration is a significant step forward in building a safer, more resilient future for aviation.

Backed by Qantas' recent $40 million investment in aviation training and skills development, this Academy will focus on delivering cutting-edge safety training to the next generation of aviation professionals. By leveraging the expertise of Qantas' world-class safety practices and the University's academic leadership, we aim to set new benchmarks in safety standards for the aviation industry.

? This initiative is designed to:

- Equip students and professionals with advanced safety competencies
- Foster a culture of safety excellence across the aviation ecosystem
- Meet the evolving demands of the industry as we look to the future

I'm incredibly proud to be a part of this transformative journey, and I look forward to seeing the positive impact this Academy will have on aviation safety worldwide.

Ref: https://www.qantasnewsroom.com.au/media-...itiatives/

Hmm...Lea Vesic why does that name ring a bell...

Aviation & Maritime Advisor 

Office of the Deputy Prime Minister of Australia - The Hon. Michael McCormack MP

Mar 2020 - Jul 2021 · 1 yr 5 mos

Canberra, Australian Capital Territory, Australia

MTF...P2 

[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 

[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."

Addendum: Coroner Report - https://auntypru.com/wp-content/uploads/...Signed.pdf

RECOMMENDATIONS

I make the following recommendations under section 72(2) of the Act –

1. That CASA review the conduct of RAAus during this investigation and inquest,
including the conduct of its officers and key personnel.

2. That CASA facilitates amendments to Section 2.13 of the RAAus Flight Operations
Manual:

(a) to clarify the aeronautical experience that may constitute “recognised flight
time” according to each aircraft type or group for which the experience is
required;
(b) to clarify the aeronautical experience required for endorsements;
© where flight testing is required for a particular endorsement, to clarify
whether such flight testing may be conducted concurrently with flight testing
required for pilot certification or other endorsements.

3. That CASA facilitates amendments to the RAAus Flight Operations Manual to
include a definition of “aeroplane” consistent with the definition found in the Civil
Aviation Safety Regulations 1998, and a definition of “aircraft” consistent with the
definition found in the Civil Aviation Act 1988.

4. That RAAus develops standardised training records for use by RAAus flight
instructors which:

(a) permit detailed auditing of the training delivered by RAAus flight instructors
to student pilots or pilots seeking endorsements;
(b) are in a form approved by CASA; and
© must be used by all RAAus flight instructors in all instances.

5. In light of the declaration by RAAus that it will no longer investigate fatal accidents
involving RAAus registered aircraft, that the ATSB should investigate all fatal
accidents involving such aircraft.

[Kharon]

"The road to hell is paved with good resolutions". (Rambach 1811).

It is feasible (in principal) to be ambivalent toward the 'notion' of RAAus; which, as a platform to encourage aviation and provide for those without intent to make a 'living' from an air-frame in a commercial sense. It provides for those who take their flying passion and can afford it seriously, offering many avoidance's of the serious impost CASA imposes on commercial operations. To the men and women who have transferred their hard won CASA brief to conduct 'private' operations and enjoy the freedoms of non 'operational' flight it is a gift from the gods. Bravo all who enjoy that freedom. However – (had to be one); may I draw your attention to the Vic Coroners report _ HERE – it is worth the time and effort. I suggest starting at about 'item 127' and going through to about the high mid 200  series. Only my opinion from here – but the Coroner has (I believe) seen, ruled on and eloquently elaborated many of the 'private' concerns many have held since RAAus inception. Opinions oft voiced over a quiet Ale or two; but shrugged off as moaning; or dismissed on a fine day for a jolly in the toys. ('tis true).

“Power is an instrument of fatal consequence. It is confined no more readily than quicksilver, and escapes good intentions as easily as air flows through mesh.”

Aye; there (as the Bard says) is the rub. Many others have made similar comments related to power corrupting; there's volumes of wise counsel related to that particular phenomenon; no matter how it is phrased, that message rings clear.

“...she moved about in a mental cloud of many-colored idealities, which eclipsed all sinister contingencies by its brightness.”

But do read through the Coroner's remarks; they paint an accurate picture of good intentions shot to Hell – add in the need for a 'business' to make money and consider the cost of the hearing to the organization and the character of the major players and it soon becomes apparent what needs to be done – management wise. Then consider the almost submerged ice berg – the training and qualifying of the pilot. First item, navigation for cross country. A Private pilot (CASA model) must pass a navigation theory exam – just the basics – not this fellah. Most can draw a line on a map, understand the symbols, air space designation, read a compass and allow for its vagaries; probably even find their way across the continent without too much ado; Hell, they may even be able to translate a weather forecast into a sensible Go-No go discussion. Not the dead pilot though; punch in the GPS sit back and enjoy the ride. 3.6 hours Nav training – BOLLOCKS. Well done that Coroner; proving the rule that you can fool some of the people some of the time; but, not all the time. Change of management ?– what a good idea.

Toot - toot.

[Kharon]

A visitor and some stray thoughts.

Ramble warning - .

All was quiet; I worked steadily, seeking 'accuracy' rather than at 'speed' – no rush; lost within the work piece. The noise of tyres on gravel was met by the dogs getting interested – it was an old friend. I made coffee, broke out the forbidden biscuit tin – he chose a bench stool so, we sat at the workbench: well he sat. I was about to sharpen a plane blade and a chisel just before he arrived; the gear for that task is always close to hand, so while we chatted I put an edge on the steel. In a while (7 perhaps 8 minutes later); I too, sat on a bench stool. “How the “(!@#$%) did you do that? He asked. “What” say's I puzzled. I gave him the short version; been doing 'that' since the age of about seven in Grand- Papa's workshop – and do it on average about three times a day; it is a 'learned' skill in constant practice. After he departed; it got me thinking; which is the reason for this long ramble; there is a point (albeit) long winded. 

“I have only made this letter longer because I have not had the time to make it shorter."

Retention of 'skills' and of 'learning' – stuff to pass an exam and stuff that will keep you alive and get you home at night. (Gods willing, weather permitting). Morse code is a classic example, back in the day 10 WPM (received) was a requirement. An old mate was an ex RAF Navigator (among other qualifications) and radio Nav Guru. He reckoned that to 'learn' Morse, the best way was to send and receive. We jury rigged a key and 'beeper' and I spent what time I could spare learning to send. For many (many) years across much of this planet the 'skills' learned and the understanding of the vagaries of radio served me very well indeed. Same applies to plotting a radio bearing fix on a chart, VAR approaches  and many other now redundant skills. One of the best examples in the Gnomic Polar chart – a real head scratcher (or Stellar {Astro} Nav) another – until you finally 'get-it'. The point of all this is a 'skill' learned which is no longer in everyday day use may not be 'forgotten' but it is filed away in the basement. Yes, it truly served to widen the horizons and provided 'tools-of- trade' - rusty now, but, an essential part of the mindset when operating an aircraft. Flying is a thinking mans job, for careful folk, who work out the weather, plot and scheme to get a load on – legally – and maintain reserves – and work out the best way to beat the winds and weather.

“Any fool can know. The point is to understand.”

Twain underscores the point for me. I have now fully read the Vic. Coroners report _HERE_ into yet another RAAus fatal event. On several levels, it is worthy of serious consideration, given the number of fatal and serious 'event's' recorded over the last few years. Don't misunderstand me; I think it is brilliant that folk with a 'medical' issue or those who simply enjoy the freedoms of the sky without the constraints CASA impose and can toddle off for weekend without too much 'legal' anxiety. (Nuff said). But, it makes me wonder though; wonder about the 'depth' of retention of 'lessons' toward examination; which seem to be soon forgotten. For instance a 'short' happy-crappy meteorology self study exam does not, nor can it, ever provide a 'sound' basis for future operation in years to come. You need to have a handle on this stuff; a real grip. Picking up a forecast should be like picking up a chisel and sharpening it without too much effort, cursing or time. A 'quick' course and a multi clue exam paper fails; at every level to qualify. Not only that, but because it was 'cheaply' gained it is soon discounted and disregarded. I ain't advocating anything like the Brit ATPL Met exam – but the most valid reason for these continued excursions into IMC by VFR pilots smacks of a very convenient “not our fault” escape clause. Tick a box and get out of jail. Nice work if you can get it. I just feel a little sorry for those who did retain and apply the basic lessons and have great admiration for those who continued to study and apply that knowledge. No reason for RAAus pilots to become a known hazard to navigation, the knowledge offered must be retained, applied and its limitations understood. Phew – Ramble over in the hope that something can be done to reduce the accident rate.

“We learn from failure, not from success!”

Toot – toot.....

[Peetwo]

A visitor and some stray thoughts.

Ramble warning - .

All was quiet; I worked steadily, seeking 'accuracy' rather than at 'speed' – no rush; lost within the work piece. The noise of tyres on gravel was met by the dogs getting interested – it was an old friend. I made coffee, broke out the forbidden biscuit tin – he chose a bench stool so, we sat at the workbench: well he sat. I was about to sharpen a plane blade and a chisel just before he arrived; the gear for that task is always close to hand, so while we chatted I put an edge on the steel. In a while (7 perhaps 8 minutes later); I too, sat on a bench stool. “How the “(!@#$%) did you do that? He asked. “What” say's I puzzled. I gave him the short version; been doing 'that' since the age of about seven in Grand- Papa's workshop – and do it on average about three times a day; it is a 'learned' skill in constant practice. After he departed; it got me thinking; which is the reason for this long ramble; there is a point (albeit) long winded. 

“I have only made this letter longer because I have not had the time to make it shorter."

Retention of 'skills' and of 'learning' – stuff to pass an exam and stuff that will keep you alive and get you home at night. (Gods willing, weather permitting). Morse code is a classic example, back in the day 10 WPM (received) was a requirement. An old mate was an ex RAF Navigator (among other qualifications) and radio Nav Guru. He reckoned that to 'learn' Morse, the best way was to send and receive. We jury rigged a key and 'beeper' and I spent what time I could spare learning to send. For many (many) years across much of this planet the 'skills' learned and the understanding of the vagaries of radio served me very well indeed. Same applies to plotting a radio bearing fix on a chart, VAR approaches  and many other now redundant skills. One of the best examples in the Gnomic Polar chart – a real head scratcher (or Stellar {Astro} Nav) another – until you finally 'get-it'. The point of all this is a 'skill' learned which is no longer in everyday day use may not be 'forgotten' but it is filed away in the basement. Yes, it truly served to widen the horizons and provided 'tools-of- trade' - rusty now, but, an essential part of the mindset when operating an aircraft. Flying is a thinking mans job, for careful folk, who work out the weather, plot and scheme to get a load on – legally – and maintain reserves – and work out the best way to beat the winds and weather.

“Any fool can know. The point is to understand.”

Twain underscores the point for me. I have now fully read the Vic. Coroners report _HERE_ into yet another RAAus fatal event. On several levels, it is worthy of serious consideration, given the number of fatal and serious 'event's' recorded over the last few years. Don't misunderstand me; I think it is brilliant that folk with a 'medical' issue or those who simply enjoy the freedoms of the sky without the constraints CASA impose and can toddle off for weekend without too much 'legal' anxiety. (Nuff said). But, it makes me wonder though; wonder about the 'depth' of retention of 'lessons' toward examination; which seem to be soon forgotten. For instance a 'short' happy-crappy meteorology self study exam does not, nor can it, ever provide a 'sound' basis for future operation in years to come. You need to have a handle on this stuff; a real grip. Picking up a forecast should be like picking up a chisel and sharpening it without too much effort, cursing or time. A 'quick' course and a multi clue exam paper fails; at every level to qualify. Not only that, but because it was 'cheaply' gained it is soon discounted and disregarded. I ain't advocating anything like the Brit ATPL Met exam – but the most valid reason for these continued excursions into IMC by VFR pilots smacks of a very convenient “not our fault” escape clause. Tick a box and get out of jail. Nice work if you can get it. I just feel a little sorry for those who did retain and apply the basic lessons and have great admiration for those who continued to study and apply that knowledge. No reason for RAAus pilots to become a known hazard to navigation, the knowledge offered must be retained, applied and its limitations understood. Phew – Ramble over in the hope that something can be done to reduce the accident rate.

“We learn from failure, not from success!”

Toot – toot.....

PS: UP thread link: https://www.pprune.org/pacific-general-a...st11831212

KRviator

Quote:

Originally Posted by Squawk7700

Sadly CASA don’t accept anonymous reports.

Raaus would have though and immediately realised what was going on.

My wife won’t fly with me, but she is probably more worried about the wings falling off.

It’s a tough one, he met the standard as judged by the instructor, flying a Eurofox, so a medium difficulty aircraft, did a lot of landings and did some big cross countries.

Months later, flies into IMC. Many pilots take 10-20 years to do that and still manage to kill themselves.

That's the point though, innit?

RAAus are in the doo-doo for giving him his ticket when they shouldn't have, and then trying to cover up that fact. And if someone from RAAus isn't criminally prosecuted I'll be sorely disappointed... Based on ol' mates reported attitude, I'm not convinced any further, or any HF training, would have changed the outcome to a material degree. Fully qualified and experienced pilots have done the VFR-into-IMC before with tragic results, but this blokes attitude just seems to have bought forward the inevitable.

If you're gonna do it, get a decent EFIS & Autopilot, at least you'll stand a chance of surviving the encounter....

Plus a comment Jason Vee on FB:

Jason Vee

There appears to be way too much finger pointing here, especially towards the RAAus. Reminds me of a quote I heard recently from an African. The need for the Western countries to put up fences along rivers with a sign saying ‘Danger River’, whereas in Africa, they rely on persons using their common sense to avoid danger.

It appears this accident was the result of poor decision making by the pilot. Even if the pilot involved had completed a full 50 hour PPL training course, and passed, the accident would still have likely occurred.

Is everyone saying that he would not have gained his PPL if he had trained for it, based on his poor decision making, rather than ability to handle the aircraft during a PPL flight test?.

It seems the West is hell bent on blaming someone else, and embrace litigation, rather than require individuals to use rational thinking and common sense.

I will go out on a limb, and say, this accident would have still likely occurred, if this pilot had trained and passed a full 50 hour PPL training course.

Time to stop the finger pointing and litigation, and go back to better decision making, common sense, and operating within your own experience, training and limits.

I feel for the pilots family, but it was his decision as PIC to fly that day, in that aircraft, in those conditions, and if he had even less experience than a 50 hour trained PPL, then that raises even more questions on his decision that day.

And BM's reply to that...

Benjamin Morgan

I think that most aviators understand the ultimate responsibility of the pilot in command. That fact is really not in question - he should never have placed himself in the situation that he did. The PIC responsibility aside, the real substance of this issue and debate is exactly how someone with so little experience was ever issued an RAAus Pilot Certificate, which ultimately increased the PIC's confidence to go out and get himself killed? How did this slip through the system? It has highlighted serious safety deficiencies with the RAAus self-administration system and overall safety management of the recreational sector.

[Kharon]

Cheers P2.

I had time to take a stroll through the UP thread; there are some 'good heads' on there, worth the time spent. However; (only a small one) a notion which may assist.

I spent some time today looking back at 'learned' knowledge; can't count the times that 'education' kept me out of harms way; but, I believe (firmly) that back in the early days, the thing which saved folks scraping me off a hill side or troubling the fire fighters (Bless 'em) was a humble, wonderful gentle-man known as Max Flutter(legend). Back in the day, there was 'operational control' and full position reporting. You attended the briefing office, submitted your flight plan and, if it was within the bounds of legal, then it got stamped. Before that, you had an option; pick up the 'printed' weather forecast (needed to support the flight plan) or, you found time etc 'chat with the 'Met Man'. For me it became almost a go – no go' decision if there was no one on duty. I made it a habit to rrive early enough to ensure I could spend time with Max; the 'education' freely offered was ffar and way 'superior' to any time spent on course. The man simply 'understood' the weather and could make it comprehensible to the young Luddite begging his indulgence. Typical of the 'senior' breed at the time. Engineers who always had time to explain; of CAA 'Examiners of Airmen' who always, without fail sought to put a polish on a rough performance. Same-same from grown up pilots. I could bang on.

I just wonder if the 'tick a box' system whilst 'justifying' the issue of a certificate is simply compounding a problem. CASA id off the hook; government so remote and utterly divorced as to be considered off the planet. Take a simple thing – let's say a cross-wind landing. Say the book demands that three be done to satisfy the 'requirement' – box ticked; moving on. BUT what of the 'quality' of the approach, landing, runway control and even the 'assessment' of the 'planned' approach? Sure three landings in cross-wind – TICK – but is that enough to ensure an acceptable approach and landing in seriously bad weather with horrible winds?

I don't know; but somewhere, somehow, the system is failing: there is no such animal as 'inadvertent' entry into non VMC – except perhaps on an instrument approach, at night when there is an unseen band of lower than minima cloud;or, a Genie is pissing on the windscreen, without warning.

For whatever the reasons these event reoccur, year after year, perhaps it is time a solution was sort. Some folk will never stop doing it; but maybe, perhaps, we can 'dissuade' some of the more adventurous to think twice. Old true words – 'Measure twice – cut once'.  That's it – said my say – Endit...

Toot – toot...