[Peetwo]

Finally..

Amber Millar’s parents blame CASA for daughter’s Broome chopper crash death with pilot Troy Thomas



The parents of a 12-year-old girl killed in a fatal Broome chopper crash claim the Civil Aviation Safety Authority has “blood on its hands” for dismissing complaints about dangerous behaviour involving the pilot’s helicopters a year before their daughter died.

Perth schoolgirl Amber Millar was fatally injured when a helicopter, owned and piloted by tourism stalwart Troy Thomas, crashed immediately after a high-powered vertical takeoff from an industrial area north of Broome in July 2020.

Her parents, Fiona and Clint Benbow, are calling for a royal commission into CASA after The Australian obtained documents through Freedom of Information that revealed the federal regulator knew about, and failed to act on, repeated reports of unsafe flying in Thomas’s choppers before the fatal crash.

“I am absolutely sickened to my core,” Mrs Benbow said.

“It is soul destroying to know that CASA did nothing with the evidence it had received about Troy Thomas and others except to turn a blind eye. We aren’t talking about ignoring hearsay or gossip. They had hard photographic and videographic evidence.

“If CASA is not going to act on information it receives about ­pilots and companies, why bother to have a regulator?”



Since Amber’s death, the Benbows have been asking CASA about Thomas’s aviation history and what it knew about the companies and individuals involved in the crash.

“This is the first time this important information has been brought to our attention and it is only coming to light as a result of FOI requests,” Mr Benbow said.

“It is incomprehensible, and frankly unbelievable, that CASA can claim that they were not aware of any of this when they were. If CASA had performed its duty properly, we are pretty damn certain that our beautiful Amber Jess would still be alive.”



The Australian Transport Safety Bureau’s final report into the cause of the fatal Broome crash found that vibration in the tail rotor pedals led to an overstress fracture that caused the chopper’s mid-air break-up seconds after takeoff.

The ATSB’s report also stated that Thomas had demonstrated “a high-risk appetite”, a history of noncompliance with aviation laws, was unlicensed to fly the Robinson R44 and knew there was a serious issue with it before taking off on that final fatal flight.

On June 22, 2020, Bryce McGlashan, a pilot who worked for Thomas, reported feeling an unusual vibration in the tail rotor pedals, which can indicate impending failure of a critical component. Despite this, on July 2, Thomas took his friend Ashley Sutton on an 18-minute scenic flight over water, during which Thomas felt the vibrations himself.

The ATSB says that flight carried “risk of worsening of a condition or failure of a component”, without any option to quickly land.

During that flight, Thomas texted Mr McGlashan, confirming the helicopter had a problem.

On July 3, a team of aircraft maintenance engineers performed troubleshooting involving ground running of the chopper but could not identify the defect.

The engineers allegedly phoned Mr McGlashan and Thomas to tell the two pilots that a check flight must be performed, but it was not recorded on the aircraft’s it’s maintenance release.

“The safest next step (recommended by the helicopter manufacturer) was the conduct of a graduated flight check by a solo pilot,” the ATSB report said. “However, the next and final flight involved the conduct of a high-power towering takeoff from a confined area with 3 passengers on board.

“The unnecessary carriage of passengers resulted in a significantly more severe outcome following the in-flight break-up.”



During a grilling from West Australian senator Dean Smith about Amber’s death, CASA chief executive and director of aviation safety Pip Spence said CASA could not have known about Thomas’s behaviour or reputation.

The Benbows believe CASA has been placating them for the past three years “in the hope we will go away and not make a fuss about our daughter”.

“This is a very bitter pill to swallow and to be quite frank, we won’t,” Mrs Benbow said.

“CASA has our daughter’s blood on its hands.”

From the start: 

Senator DEAN SMITH: Thank you for your time here this evening, Ms Spence, and other officials. I just noticed that your nametag says chief executive and director of aviation safety. Can you explain to me why it is necessary to have both roles?

Ms Spence: Because the job actually is two titles. One is the person responsible for running the organisation. There is also a role under the legislation as the director of aviation safety.

Senator DEAN SMITH: Have the roles always been combined?

Ms Spence: Yes.

Senator DEAN SMITH: Across Northern Australia, can you tell me the deployment of CASA officials at various aviation centres? Mr Walker was nodding his head.

Ms Spence: First of all, I should probably just point out that we do operate under a national operating model. While we do have staff located in Northern Australia from Cairns and Darwin, we are able to send resources from other areas in the organisation to support operations in Northern Australia. I will pass to Mr Walker to provide a bit more detail.

Mr Walker : Yes, we do have state offices right around Australia. In particular, for Northern Australia, there is an office in Darwin and an office in Cairns. The other most northern office would be the Brisbane office. In our Cairns office, we have roughly 23 or 24 staff. We have 11 staff in Darwin. Brisbane is one of our larger offices, with about 219 staff.

Senator DEAN SMITH: When we think of northern Western Australia, which is my home state, what is the most northern town that has a CASA presence?

Mr Walker : Generally, northern Western Australia we manage out of our Darwin office. That is also supplemented with staff out of the Perth office.

Senator DEAN SMITH: So the 11 staff that are permanently based in Darwin are also responsible for northern WA?

Mr Walker : Yes. As Ms Spence said, they are supplemented with our staff nationally. The way we run our operations for the organisation, particularly in my area of regulatory services, is that rather than being location specific, we have staff available to service those needs out of any CASA office, depending on where the surge in demand is. One thing we don't really have control over is where the work comes from and when it comes. We deploy local staff generally as a preference, particularly for regulatory services, where there is some local knowledge and particularly for our surveillance activities. Otherwise, we would defer that work to one of our other offices.

Senator DEAN SMITH: I will stay with northern Western Australia for a moment. How frequently would CASA officials or officers make themselves present at various aviation locations across the far north of Western Australia? I am thinking of Kununurra, Fitzroy Crossing, Halls Creek, Broome and Derby.

Mr Walker : Certainly. That would very much depend on what work we have afoot, particularly, as I say, for regulatory services. We would respond to service requests out of the local operators at those locations. In terms of surveillance, we have a national plan, an annual plan, for surveillance. We would look at specific operators or specific sectors and generally take a risk based approach. I couldn't say definitively that they are there every second week or once a month. It is really very driven by the work demand in those locations from those operators.

Senator DEAN SMITH: When you use the term 'regulatory services ', what does that mean in detail in terms of the sorts of activities?

Mr Walker : For any commercial operations in Australia, an operator requires an air operator certificate. It doesn't matter whether you are a large operator such as Qantas, that would have multiple air operator certificates, right down to some of the smaller part 135s, more commonly known as charter operators. As they conduct operations, they may have need to interact with us. Effectively, the way the regulations run is they require certain permissions from us to operate. In the nature of their operations, that may change quite regularly or seldomly. It really depends on the nature of the operation. If they want to introduce new aircraft to their fleet, that would be a touchpoint for CASA. If they want to change their key personnel—physically there is a change of safety managers or even CEOs—that is something they interact with us about. On any given year, we would have a large number of regulatory services as activities. It is very much driven by the permissions that industry would be seeking from CASA.

Senator DEAN SMITH: Time is of the essence. You used the word 'surveillance'. Can you provide an explanation of what you mean by that?

Mr Walker : There are two parts to it. Industry, obviously, seeks permission to do certain things. First and foremost, we make sure that it is done safely and in alignment with the regulation. We also have a surveillance component where we check and verify that industry is doing what they said they were going to do or they asked permission to do. So it's basically separating the service provision from a validation exercise to go and check that they are compliant with the regulation.

Senator DEAN SMITH: I am assuming that when CASA officials do make themselves available across far northern Western Australia—Halls Creek, Kununurra and Broome et cetera—you keep a record of that?

Mr Walker : Most definitely. Every regulatory service interaction is recorded. Obviously, we are obliged under our regulation to charge a fee for those services. Effectively, they are predetermined and agreed. Equally, for surveillance, which we don't charge for, we keep a record of that so we have as full a picture as possible of the safety operations of an organisation.

Senator DEAN SMITH: In terms of your recordkeeping, there are two sets. There is the regulatory service interaction and then there is the surveillance interaction. You note the sort of record that is kept?

Mr Walker : Effectively, yes. It is one system in terms of our record management as an IT system.

Senator DEAN SMITH: With date, day, person and operator?

Mr Walker : Correct. Right down to the storage of documents in terms of the some of the documents we would require to assess an application. It could include their flight operations manual. It could include their safety systems manuals. It could include areas such as fatigue et cetera.

Senator DEAN SMITH: Great. On notice for the period 2018, 2019, 2020, 2021 and 2022, can you provide me with information about the presence of CASA officials and as much detail? I am someone who is very happy operating in the detail. I want detailed information about the regulation service interaction and surveillance activities of those officials on those particular days?

Mr Walker : Certainly. I might need to qualify it somewhat. Not all regulatory services require physical participation at location. Generally, though, we could provide you with information on the nature of the regulatory services and the locations and the way those occurred.

Senator DEAN SMITH: It would identify whether it was done remotely or on premise physically?

Mr Walker : Generally, yes.

Senator DEAN SMITH: Great. Thank you very much.

Ms Spence: Another thing we can also provide advice on is we also have an educative role. We do have other officers who engage with industry just to determine and make sure that industry understands why the regulatory framework operates and if there are particular issues that they want to deal with. We can also talk to you about what the aviation safety advisers do who also aren't based necessarily in that region but who go out and visit operators in those areas. We will—

Senator DEAN SMITH: That will be recorded on the information there?

Ms Spence: That will be recorded in it.

Senator DEAN SMITH: Great. I want to turn specifically to Robinson R44 Raven helicopters. How many Robinson R44 helicopters are registered in Australia at the present time?

Ms Spence: We would have to take that on notice.

Senator DEAN SMITH: Are you sure you don't have it there?

Ms Spence: I'm positive I don't have that in my pack.

Senator DEAN SMITH: Would you like to take an estimate? Is it 100 or 200?

Ms Spence: I would give you an accurate answer. We will certainly take it on notice.

Senator DEAN SMITH: You are welcome to give me an answer and correct the record. You are the director of aviation safety.

Ms Spence: Yes. I don't have the number of R44 helicopters operating in Australia. I can certainly get that for you on notice.

Senator DEAN SMITH: Perhaps while we're having this discussion—

Ms Spence: If any of my team behind me know what the answer is, I will certainly jump in and let you know.

Senator DEAN SMITH: I am also interested to know where they are located. Can someone give me a figure? Are they located in Northern Australia? Are they located in Perth or Melbourne et cetera? I would be very interested in—

Ms Spence: We will give you as much information as we can. I don't know if we would have that breakdown for you. Whatever level of detail we can provide you with, we certainly will.

Senator DEAN SMITH: In the ATSB transport safety report that was done into the incident that occurred in Broome on 4 July, where a young girl lost her life, just for the record, it said there were 558 Robinson R44 helicopters in Western Australia. Before we turn specifically to the ATSB report, what is CASA's attitude with regard to the safety of Robinson R44 helicopters?

Ms Spence: It is an issue that we have been looking closely at. Probably towards the end of last year, just in response to a number of incidents involving both the R44 and the R22 helicopters, we did an analysis looking over the last 10 years to see whether we could identify any specific trends, be it location, type of operation or any other sort of causal factors that created any suggestion that there was a particular issue we needed to look into. We couldn't find any particular trends. We are monitoring it closely. We work very closely with the Australian Helicopter Industry Association. Obviously, we are concerned about the number of accidents and incidents we are seeing. As I said, we did do a review to determine whether there was anything specific that was linking the accidents and incidents.

Senator DEAN SMITH: You found it necessary to do an analysis?

Ms Spence: Yes. Based on the number of accidents and incidents that have been happening.

Senator DEAN SMITH: The analysis found no consistent determinants or issues?

Ms Spence: That's correct.

Senator DEAN SMITH: Did other aviation experts outside CASA find that analysis surprising or reassuring?

Ms Spence: We haven't discussed that with any other aviation experts.

Senator DEAN SMITH: Did the Robinson R44 helicopter manufacturer participate in that analysis?

Ms Spence: No. It was based on the data that is available. It is based on ATSB accidents and incident reports.

Senator DEAN SMITH: In Australia?

Ms Spence: In Australia, yes.

Senator DEAN SMITH: You didn't think it necessary to inquire about accidents that might have happened outside Australia?

Ms Spence: I would have to get back to you with the detail of what other factors they looked into as part of that analysis we did. I am certainly not saying that it is the end of the work that we are doing looking at it. Based on the work we have done to date, we haven't seen any causal factors that we need to act on.

Senator DEAN SMITH: So the incident that happened in Broome on 4 July, was that one of the incidents that assisted CASA come to the view that it was necessary to do this analysis?

Ms Spence: Yes. It would have been one of the accidents. As I said, it was in the 10-year time frame, so it dated back from any accident or incident from, I think, the start of 2022 back to 2012.

Senator DEAN SMITH: And the analysis found no consistent—

Ms Spence: No causal links or anything that gave rise to us to do further analysis. As I said, we are continuing to work with the Australian Helicopter Industry Association. We will continue to monitor and undertake any work we need to.

Senator DEAN SMI TH: Has that analysis been peer reviewed?

Ms Spence: No. I don't think so.

Senator DEAN SMITH: Will it be?

Ms Spence: No.

Senator DEAN SMITH: Why not?

Ms Spence: We didn't have plans to do that. I can certainly take on notice what—

Senator DEAN SMITH: You obviously thought there were enough incidents to warrant CASA doing an independent analysis.

Ms Spence: Yes.

Senator DEAN SMITH: The independent analysis found no consistent causal influences or issues?

Ms Spence: Yes.

S enator DEAN SMITH: I would have thought from an aviation security perspective and abundant caution that a peer review might have been—

Ms Spence: I think it was because of the nature of the analysis done. The data is the data. We were looking at whether there is any trend. I am not saying there isn't further work we can do. It's a sensible suggestion that you are making. I will look to see what else we can do in that space.

Senator DEAN SMITH: Is the analysis a public document?

Ms Spence: No. It's not.

Senator DEAN SMITH: Will it be?

Ms Spence: Can I take that on notice, please?

Senator DEAN SMITH: Is it your decision?

Ms Spence: I would like to review the document to determine what the best course of action would be.

Senator DEAN SMITH: That is separate to my question. Is it your decision about whether or not the analysis becomes a public document?

Ms Spence: I would want to consult with the board before I release the document.

Senator DEAN SMITH: Thank you very much. I will turn specifically to the issue with regard to Broome on 4 July 2020. What is CASA's general attitude with regard to that?

Ms Spence: Apart from the obvious statement that it was a tragedy—

Senator DEAN SMITH: Of course, yes.

Ms Spence: and terrible that it happened, one of the points that the ATSB made clear in the analysis or their investigation is that this was a private operation. The way in which our regulatory framework is established, we do have a high level of expectations around those operators who we authorise. As Mr Walker said, they have an air operator certificate. They are essentially providing commercial transport services. There are still requirements, obviously, and expectations on private operations, but they do not meet the same safety standard as what you would expect for a commercial operation.

Senator DEAN SMITH: In your statement of 14 April 2023, which I think might have been released in response to some media inquiry—

Ms Spence: Yes.

Senator DEAN SMITH: you do make the point that the accident flight was not a commercial tourist operation but a private flight organised for family and friends.

Ms Spence: Yes.

Senator DEAN SMITH: You then go on to say that private pilots conducting private operations for family or friends must still follow the aviation safety rules, including a requirement to hold a valid and current licence.

Ms Spence: That's correct. If the pilot hadn't been deceased, we would have taken action. What the pilot did was illegal.

Senator DEAN SMITH: What actions has CASA taken since the release of the ATSB report on 12 April this year?

Ms Spence: I might get my colleague to come to the table. Essentially, we have done extensive campaigns to educate pilots on what is appropriate and how to operate legally. We are working again with the Helicopter Industry Association to see whether there are any ways that we influence behaviours of pilots. We are looking at how we best ensure that pilots are aware of when certain requirements, such as their medicals, have expired. We already give them notice around that. It is about whether there anything else we can do to make sure that they make all the effort to maintain currency. I might turn to my colleague, Mr Marcelja.

Mr Marcelja: Within my remit is safety education for pilots. As Ms Spence said, the approach we take for private operations is very much around raising awareness and educating. We have many different campaigns, including seminars to pilots and online training. We have been running a pilot safety campaign since about August last year. That is specifically targeting safety behaviours in pilots. We are getting some really good uptake and participation in that. It is very much an educative approach. We have about 30,000 plus pilots in Australia. Helicopters make up maybe 10 per cent or so of that.

Senator DEAN SMITH: To be clear, we are talking about a particular type of helicopter and a particular type of activity in a remote part of Northern Australia. Mr Walker, you talked about risk management techniques. The ATSB report does demonstrate that there was more than one incident with regard to the pilot. I am curious to know why the risk management technique you talked about did not identify this. I understand the importance of the education campaign, but, to be fair, it sounds generic.

Mr Marcelja: I think the point I'm making and that the director was making is that our surveillance, enforcement and oversight activity is very much focused on commercial operations. We focus very strongly on commercial operators and tourism operators.

Senator DEAN SMITH: I am not an aviation expert. As a layman, reading the ATSB report makes it very clear to me that the emerging risk is actually amongst private pilots and private operators. I am keen to understand what you are doing to mitigate what I would characterise as an emerging risk.

Ms Spence: One thing I would like to clarify is that we did obviously look back—that is one of the things we do—to see what visibility or awareness we had of the pilot and any incidents that he had been involved in. All we found was one incident that had been acquitted. If you get a demerit point and then that demerit point is—

Senator DEAN SMITH: What was that one incident?

Ms Spence: I will have to take it on notice. I'm sorry. I thought had a piece of paper here.

Senator DEAN SMITH: A helicopter crashing on a boat?

Ms Spence: No. It wasn't.

Senator DEAN SMITH: Another incident in addition to that?

Mr Walker : I think I understand the incident you are talking about. It is the same incident that Ms Spence is referring to, which is flying too low. It was in the close proximity of a boat.

Senator DEAN SMITH: It hit the boat.

Mr Walker : It hit the boat; correct.

Senator DEAN SMITH: It hit the boat.

Ms Spence: And the incident was investigated. There was a requirement on the pilot. I can't remember what he had to do. There were actions taken.

Senator DEAN SMITH: Again, I am a layman. On my reading of the report, I identified these issues. There were issues around the pilot's licence, issues around the maintenance release and issues around the previous instances of poor pilot practice.

Ms Spence: Can I just point out that is one—

Senator DEAN SMITH: That is already three. There is the existence of non-reported incidents. I have here four.

Ms Spence: The maintenance release one is a very important one. Obviously—

Senator DEAN SMITH: It's serious.

Ms Spence: It's very serious. Again, that goes to the—

Sen ator DEAN SMITH: A young girl and another passenger, in the interests of full transparency, lost their life. It appears to me, again as a layman, that here was a recurring set of circumstances in a remote part of Western Australia, which, to be fair, is well-populated in terms of remoteness. To go back to where I started, I was interested in understanding CASA's presence. This is an area that has pastoral populations and pastoral pilots. It is heavily dependent on the tourism industry. Here is a set of circumstances. When we started, I was not convinced that CASA's physical presence in a place such as Broome is sufficient in order to police and protect.

Ms Spence: First of all, if reports are unreported, we can't take action on them. I am not trying to be cute or smart on that. What we don't know we don't know.

Senator DEAN SMITH: Ms Spence, there were YouTube videos.

Ms Spence: We don't spend our time scanning YouTube videos.

Senator DEAN SMITH: So your surveillance activity does not involve monitoring or policing advertisements of tourist operators?

Ms Spence: Can we please be very clear? This is not a tourism operation. It was a private pilot.

Senator DEAN SMITH: By your own media statement, you have said that private pilots conducting private operations for family or friends must still follow the aviation safety rules. You are the aviation regulator.

Ms Spence: The pilot broke those rules. I totally agree with that. If the pilot had survived, we would have taken enforcement action. What I am trying to say is that it was a private pilot in a private operation who did the wrong thing.

Senator DEAN SMITH: It was not invisible. There was recurring behaviour on the part of the private pilot, I would contend.

Ms Spence: I would contend that there was an incident that we were aware of. There were actions taken. He did what he was required to do. I don't think you can point to a recurring trend of us not acting on something.

CHAIR: I am loathe to come in. I can't express my condolences deeply enough for the families of the two people who lost their lives. I am keen if you want to keep going, although it has nothing to do with the budget. I know how flexible we have been in this committee. It is 10 o'clock. I will seek support from my colleagues. If we are going to continue questioning for CASA, because I know Senator Roberts has questions, are we still likely to get to the Northern Australia Infrastructure Facility? We are.

Senator DEAN SMIT H: Chair, thank you for your indulgence. You did give me the call. I will just take three more minutes, if that's okay.

CHAIR: Yes, fine, thanks.

Senator DEAN SMITH: We can pursue this in a private briefing if the minister is so inclined. What has CASA done since in the detail? Has CASA taken the initiative to speak to the family?

Ms Spence: No. We haven't.

Senator DEAN SMITH: Has the family requested an opportunity to speak to CASA?

Ms Spence: Not that I'm aware of.

Senator DEAN SMITH: Mr Walker?

Mr Walker : Not that I am aware of, no.

Ms Spence: I totally agree that it is a tragedy. We would like to make sure that they understand what happened and why we are taking our responsibility seriously.

Senator DEAN SMITH: I think yes, I agree, Ms Spence—what happened and future remedies and future mitigation.

Ms Spence: Yes.

Senator DEAN SMITH: Absolutely. Assistant Minister, congratulations on your additional responsibilities. Will the minister make herself available to meet with the family to discuss how these sorts of terrible incidents can be mitigated against in the future?

Senator Chisholm: I am sure the minister would make herself available if that were appropriate.

Senator DEAN SMITH: My last question goes to something I saw in some previous ATSB reports in terms of doing some due diligence on this matter. I understand that there is a section on what has been done as a result. Is that a regular feature of ATSB reports? Is it an ATSB responsibility or a CASA responsibility?

Ms Spence: I think they tend to report after the accident. We provide them with information that they would include in their report to say actions that have been taken to address the issues that they have identified.

Senator D EAN SMITH: And CASA did provide information to the ATSB on this matter for this report?

Ms Spence: This predates my tenure in the organisation. I would have to check. I assume that we would have.

Senator DEAN SMITH: Mr Walker?

Mr Walker : It likewise predates my tenure in this role.

Senator DEAN SMITH: Mr Monahan?

Mr Monahan: It predates me as well.

Mr Marcelja: As a matter of course, we typically do. While we will check the detail for you, we typically do.

Senator DEAN SMITH: Yes. That is my understanding as a matter of course. My question goes to whether that matter of course continued in this instance. Thank you very much, Chair. Thank you, Ms Spence, and other officials for that. We will absolutely take up the opportunity to meet with the family. It is a tragic set of circumstances. Could you take on notice whether or not CASA will release that report and/or have it peer reviewed? I appreciate that. Thanks very much for your time.

“No, I do not weep at the world – I am too busy sharpening my oyster knife.” ― Zora Neale Hurston

I too am 'busy sharpening my oyster knife' - bring on a Royal Commission into CASA, this case is just the tip of the oyster shell...

MTF...P2