ATSB investigation into plane crash which killed three raises concerns about Angel Flight


August 13, 2019 18:22:40

Analysis by the Australian Transport Safety Bureau (ATSB) has found that community service flights conducted by charity Angel Flight Australia have a fatal accident rate more than seven times higher than other private flights.

Key points:

  • Emily Redding, 16, mum Tracy and pilot Grant Gilbert were killed in the crash
  • Mr Gilbert’s single-engine light plane crashed shortly after take-off at Mount Gambier in 2017
  • The Australian Transport Safety Bureau has conducted a lengthy investigation

The key finding was contained in a report into a plane crash that killed three people — including a mother and her teenage daughter — near Mount Gambier in South Australia’s south-east on June 28, 2017.

The investigation also revealed the pilot of the single-engine plane was not qualified to be flying in cloudy conditions.

Emily and Tracy Redding, aged 16 and 43, were killed along with 78-year-old pilot Grant Gilbert when he crashed upside down in heavy fog, on the edge of a field about two kilometres from the local airport.

Mr Gilbert volunteered his aircraft for Angel Flight, a charity that coordinates non-emergency flights by recreational pilots to help country people reach medical treatment and appointments.

However, a two-year ATSB investigation into the accident took a much more detailed look at Angel Flight’s crash rate, after another fatal incident which killed three people in 2011.

It found pressures associated with transporting medical patients were leading to riskier flight behaviour by pilots.

“The average likelihood of a fatal accident involving an Angel Flight organised passenger-carrying flight was more than seven times higher than other private flights,” the report stated.

“There was an increased prevalence of flight preparation and navigation errors in Angel Flight community service flights, compared with other private operations.

“This is a known precursor to fatal accidents, and was identified in both fatal accidents involving Angel Flight.”

The previous fatal crash, near Horsham in Victoria in 2011, also killed three people including another mother and her teenage daughter.

The ATSB found the most likely cause of that crash was poor visibility — but the two accidents prompted strong calls for better safety and regulation.

“Passengers on these flights and their pilots are being exposed to much higher levels of risk compared with other types of aviation operations,” ATSB Chief Commissioner Greg Hood said.

“The community could reasonably expect that community service flights would have a level of safety at least commensurate with other operations.”

Angel Flight conducts about 1,600 flights every year and the ATSB acknowledged the flight provider had taken steps to improve safety, including an online safety course and a pilot mentoring program.

But the watchdog made a stronger, formal recommendation, urging the provider to “consider the safety benefits of using commercial flights where they are available to transport its passengers”.

It said Angel Flight could buy tickets on commercial flights for two passengers for a “comparable cost” to what volunteer pilots receive to reimburse them for fuel.

“On the day of the Mount Gambier accident, suitable and cost-comparable airline flights were available,” Mr Hood said.

Pilot ‘was not qualified’ and became disorientated

On the day of the accident, the pilot was transporting the two locals to Adelaide for medical reasons when his Socata TB-10 Tobago crashed about 70 seconds after take-off from the town’s airport.

Mr Gilbert was a respected businessman from Mount Barker in the Adelaide Hills, and a friend of Premier Steven Marshall.

The ATSB said Mr Gilbert had been flying for two years, did not have the necessary experience to fly in cloud and likely became confused in the moments leading up to the crash, when the plane began descending during a left turn.

“He was not qualified or experienced in conditions requiring instrument flying proficiency, which was what the conditions on departure from Mount Gambier required for safe flight,” the report stated.

“On entry into low cloud, the pilot … would have lost visual cues, in particular the horizon and visual reference to the ground.

“It is well established that a loss of visual cues significantly increases the risk of spatial disorientation.”

The ATSB found the plane was upside down when it slammed into the ground, about two kilometres from the airport, causing a loud bang heard by several witnesses about 10:24am.

The force of the impact caused the plane’s engine and propeller to break off, and left a debris zone covered in aviation fuel.

An earlier, preliminary report stated that a portable locator beacon was found in the cockpit, but had not been activated.

“The ATSB found that the Angel Flight organisation did not pressure pilots to fly in conditions beyond their capability,” Mr Hood said.

“But some circumstances can lead to a pilot feeling pressure in any case such as having the responsibility to fly unrelated ill passengers to meet [a] medical appointment deadline.

“This can lead to degraded decision-making under highpressure situations, such as when confronted by poor weather.”

Angel Flight passengers ‘survivors, not clients’

Brian Perry, the father of Tracy Redding, and grandfather of Emily, said his life had become a “nightmare” since the Mount Gambier crash.

“It’s never going to go away. I won’t go near a plane now. I used to fly gliders, but I won’t go near a plane,” he said.

“Anybody who’s been on an Angel Flight and landed and lived — they’re not a client, they’re a survivor.”

Mr Perry said he was concerned people were using it as a “flying club — get free fuel, have a lovely trip”.

He believed the ATSB had done a good job in investigating the crash and highlighting concerns about the Angel Flight model.

The ATSB has previously said no emergency call was made by the pilot before the crash, and the plane was not required to be fitted with a flight data recorder or cockpit voicer recorder.

The accident happened about two-and-a-half hours after Mr Gilbert had left Murray Bridge.

Conditions around Mount Gambier were foggy at the time, and a map of the plane’s penultimate flight path on approach to the local airport shows a “significant deviation” from the direct route.

The ATSB previously reported that the plane may have attempted to land, before a “series of low level turns” and a landing on an adjacent runway.

The same day, two Regional Express (Rex) Airlines flights destined for Mount Gambier were delayed or grounded because of weather conditions.

The aviation watchdog said Angel Flight services were essentially no different to private flights “which the Civil Aviation Safety Authority (CASA) defines as flying for pleasure, sport or recreation”.

In the wake of the crash, CASA imposed new minimum safety standards requiring community flight service pilots to have at least 250 hours of flight time at the controls.

Charity hits back at ATSB

In a statement, Angel Flight said it was “committed to safety and welfare as its priority”.

“It is regrettable that the bureau made no relevant safety recommendations, nor gave any guidance whatsoever, to pilots flying in poor weather conditions — the cause of the accident,” it said.

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

“The safety message raised — induction training and safety management systems, together with a pilot mentoring program — had already been implemented by the charity prior to the ATSB report and recommendations.”

It said the ATSB failed to include flights without patients on them to their hometowns, doubling the crash rate.

“Angel Flight has coordinated more than 46,000 flights for the purpose of travelling to, returning from and carrying rural Australians to the city for non-emergency medical appointments,” it said.

“The ATSB has excluded more than half of these flights when assessing accident rates, with the result being to substantially increase the alleged statistical accident rates.”














First posted

August 13, 2019 10:20:12

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