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.