A senate committee has placed the Australian Transport Safety Bureau's (ATSB) investigation report in the the 2017 fatal crash of an Angel Flight aircraft at Mount Gambier under severe scrutiny.
The pilot was on a VFR Angel Flight mission to Adelaide in June 2017 when the Socata Tobago he was flying crashed trying to depart Mount Gambier in weather that was below visual conditions. The pilot and two passengers were killed.
In their investigation report, the ATSB focused on the management of Angel Flight and made no recommendations relating to the actions of the pilot on the day.
In a public hearing of the Senate Standing Committee on Rural and Regional Affairs and Transport (RRAT) held in Sydney on Wednesday, the ATSB and CASA were both grilled over their handling of community service flights (CSF).
The RRAT committee called into question the statistical analysis used in the report to show that CSFs were less safe than normal private flights and whether or not there was increased pressure on pilots during CSF missions.
Appearing for Angel Flight, CEO Marjorie Pagani laid out the issues that her organisation had with the report in her opening remarks.
"In relation to the ATSB report, the primary issue we take with that is that it is wrong, it's dishonest, it's misleading, it uses inventive and flawed datasets, it targets unfairly a charity and it does nothing to investigate the accident or to give any guidance or recommendations into how this sort of thing can be prevented in the future," Pagani said.
Pagani also questioned if the ATSB had a pre-determined mind-set that Angel Flight contributed to the crash.
"At the accident scene in Mount Gambier, the lead investigator, with no experience in aviation, stood before national television and said: 'We will be investigating Angel Flight.' And that's what happened. That was at a time, senators, when the ATSB had not even given Angel Flight the courtesy of a confirmation that this was an Angel Flight related accident."
ATSB Chief Commissioner Greg Hood stuck to the premise that Angel Flights represent a higher risk to safety.
"By any measure, there is a different and elevated risk for community service flights operated by Angel Flight Australia compared to other private flying operations and commercial air transport," Hood stated. "Similar risks were identified in the United States a decade ago, and independent statements from Australian community service flight pilots show that there is already this understanding in Australia as well."
Liberal Senator Slade Brockman fired questions at the ATSB via a telephone link, homing in on the validity of the statistics used to establish that Angel Flight missions were less safe than normal private operations.
"There is an 82.2% probability that the accident rate for private flights is higher than for Angel Flights," Brockman said. "I would assume that you would put that to one side and say it's a statistical anomaly based on a small number of data points.
" ... in a category of accident rates for Angel flights versus private flights, there was a 17.8% probability that Angel Flights were more accident prone. That being the case, it means there is an 82.2% probability that private flight accident rates were higher than those for Angel flights in that category."
Centre Alliance's Senator Rex Patrick opened a wound when he asked Hood how many Angel Flight pilots the ATSB had spoken to in gauging the level of pressure they felt during missions, which was an outstanding question taken on notice at a previous senate estimates session.
"Have you talked to a number of Angel Flight pilots—if so, how many?—in respect of pressures that might be put on them relating to community service flights? You said: 'We have talked to Angel Flight pilots. I'd have to take on notice how many.'
"The answer you gave me is one of the most unsatisfactory answers that has ever been presented to this committee, in my view. You said: 'Over the course of the investigation (AO-2017-169), the ATSB interviewed a number of pilots with varying backgrounds. The ATSB can provide a number after completion of its investigation.'
"I was specifically after the number of pilots you talked to, because at that point in time you had prepared a draft report, and it's highly relevant to the conduct of your organisation as to how you've done consultation. That question was not answered, and I want to know how many pilots you had spoken to up to the date 8 April 2019."
Ultimately, ATSB Director Dr Stuart Godley was left to field the ball, admitting: "We didn't speak to any pilots about whether they've experienced perceived pressure. That's because we were very confident in the argument. We had submissions to the 2014 CASA instruments where some people showed that they have perceived pressure. We have evidence from the US where investigations by the NTSB, the equivalent of us, found the same thing."
Senator Patrick also leapt on the ATSB after it was revealed that they had no figures on how many Angel Flights had been canceled by pilots who were not comfortable with the mission.
"I would have thought: you're looking at pressure points and cultures of organisations, yet you haven't talked to a pilot and you're unable to tell us about what I would consider to have been a pretty obvious thing to do, which is to go and ask, 'There's pressure on people to complete these flights; how many pilots cancelled?'"
Godley reiterated the issue of pressure, telling the RRAT it was about the health state of the passengers.
"It's the sort of pressure where you're carrying people that are often unknown to you," he said. "They're relying on you. They're sick. You've got to got to meet a schedule, a deadline to bring them to a medical appointment. You've got to travel to a big city.
"All these things are potential pressures that may affect some people some time, and they definitely do affect some Angel Flight pilots some of the time. It doesn't really matter if it affects all 3000 or actually only 50, because that's out there and that's potentially leading to an accident."
RRAT committee Chair, Labor's Senator Susan McDonald asked the pointed question about whether or not the ATSB considered that airline pilots were superior to GA pilots. Initially, Hood and Godley provided evasive answers until commissioner Chris Manning took it head on.
"I know a lot of pilots. The answer is no," Manning told the committee. "There are very good pilots in all spheres of aviation. There are some average ones and some below-average ones in all spheres. Obviously, airline pilots are trained continually; their training is continuous, so you expect them to get to a higher standard. But, whether they are innately better—I think that's fallacious, because they're probably not.
"Take Angel Flight: there are some very good pilots. I know a lot of them, and they're airline pilot type people who do it on the side. As in all spheres of aviation, there are the ones down the bottom. That's what happens."
CASA Acting CEO Graeme Crawford defended the Community Service Flight (CSF) regulations introduced in March this year, saying that "the instrument demonstrates a risk based, proportionate approach to the identified risks, with the aim of ensuring the safety of passengers carried on CSF flights."
Crawford also stated that Angel Flight had confirmed that the legislation had had no adverse impact on their operations.
The committee also called into question the CASA legislation that demanded an increased maintenance schedule for aircraft used in Angel Flights.
CASA's CSF legislation is still subject to a Centre Alliance Disallowance motion and the statistical analysis is being challenged in the Federal Court, with the next hearing due on 17 September.
CASA and the ATSB have been given two weeks to provide answers to questions taken on notice, with the matter no doubt to be raised again in senate estimates sessions scheduled for 21-22 October.