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Angel Flight – Senate Inquiry

The current inquiry by the Senate follows the loss of Don Kendall in the first Angel flight crash in August 2011 and the subsequent Mt. Gambier accident.

The inquiry is looking at whether or if there is a basis for the #atsb report and the findings.

We note that this is not the first #atsb report, where doubts have been raised on the veracity of the report, much less the reporting standards.  [PelAir  and   Norfolk Island]

David Forsyth in 2014, raised serious doubts that were similar in his #ASRR review.

The question needs to be raised:

Has #atsb and #casa learnt the lesson.

Should #atsb and #casa be brought back into the direct Government reporting structure and be directly responsible to a separate #aviation Minister, rather than this indirect management that prevails in 2019.

Here’s a thought. In the #Lockhart River #atsb report, the #atsb failed to interview key personnel involved in the flight.

Track of VH-POJ in 2011










This morning, Angel Flight wrote the following after the commencement of the Senate hearing in Sydney on 4th September 2019:

Most of you would be aware that we appeared before a public inquiry (on Wednesday) into the ATSB and CASA, in relation to the ATSB Report and the CASA CSF Rules.

After many requests for an answer by Senator Patrick directed to the ATSB, they finally conceded that they had not interviewed one single pilot before reaching their conclusion that there was ‘perceived pressure’ on volunteer flights – a significant matter as this assumption was central to their findings.

CASA admitted its rules may be ambiguous, and conceded it was an error to include helicopters. It has been required by the Inquiry (for the second time) to provide its safety case within two weeks.

The Senate committee will consider the evidence at the close of the evidence.

We would like to express our appreciation to all of the RRAT committee, in particular Chair Susan McDonald (Qld) and Rex Patrick (SA) for steering this important investigation, and giving us the opportunity to present our data (by independent experts) which shows clearly that the ATSB report and assumptions are seriously flawed, and to require both agencies to be accountable for their actions, which have adversely affected the general aviation community, and the disadvantaged people of rural Australia.

We would also like to thank our volunteer pilot and hon. Safety Manager Dr Owen Crees, for his invaluable assistance, and Ben Morgan and AOPA for the tireless efforts directed to protecting the rights of pilots to fly without unnecessary and unfair restrictions and costs. I urge those of you not already members of AOPA to consider joining, to help strengthen this important advocacy organisation.


Marjorie Pagani
Chief Executive Officer
Angel Flight Australia

 Operation of the Australian Transport Safety Bureau, and in particular its report on the June 2017 crash of a flight conducted on behalf of Angel Flight Australia

The Senate Rural and Regional Affairs and Transport Legislation Committee is conducting an inquiry into the operation of the Australian Transport Safety Bureau, and in particular its report on the June 2017 crash of a flight conducted on behalf of Angel Flight Australia, under Standing Order 25 (2) (a).

Submissions close on Wednesday, 4 September 2019.


Submission 1 – Mr Howard Hobbs

Submission 2 – Mr Shaun Aisen

Submission 3 – Mr Allen Hilton

Submission 4 – Civil Air Australia

Submission 5 – Mr John Raby

Submission 6 – The Australian Aviation Associations’ Form

Submission 7 – Mr Alexander Reith

John Raby, in his senate submission notes the following:

Just for a moment look back on the period since the first fatal accident to an aircraft involved in CSF [Community Service Flights]. There have been to my knowledge at least another six similar fatal accidents to general aviation aircraft in Australia which have been the subject of ATSB reports.

  1. 15 August 2011 Piper PA28-180 31 kilometres North of Horsham Victoria (CSF)
  2. 7 November 2015 Airbus Helicopters EC135TI Cooranbong N.S.W. (Private)
  3. 29 January 2016 Piper PA28-235 33 kilometres South East of Avalon Victoria (Private)
  4. 7 April 2016 Robertson Helicopter R22 BETA (Private)
  5. 16 June 2017 Cessna 172 North West of Ballina N.S.W. (Private)
  6. 28 June 2017 Socata TB10 Mt. Gambier South Australia. (CSF)
  7. 4 February 2019 Pilatus Britten Norman BN-2A-20 Tasmania (Charter)

Another accident in the United States has chilling similarities to the Mt. Gambier accident.

24 December 2017 Cessna C340 Bartow Florida USA. (Private)

Note: The above list is from personal knowledge and therefore not exhaustive and does not include several serious non fatal incidents in Australia. Reading the ATSB and NTSB reports of these accidents reveals similar human frailties leading to tragedy. That is a single minded focus on completing the task despite all indications pointing to challenges well beyond the capabilities of the pilots. Importantly although the single minded focus was identical the factors underlying the tragically poor decision making were different.

For example:

  • A desire to assist others in need.
  • To reach a holiday destination.
  • To complete planned flight which had been much delayed in instrument flight conditions.
  • To meet a maintenance requirement within the regulations.
  • To complete a flight which if not undertaken would result in stranded passengers.

The submission of the TAAF group is quite at odds to the other six submissions offering un-conditional support to #casa and #atsb.


Senate RRAT Hansard report



#aopa on it’s website says it has conducted a “…ring-around poll…” of TAAF members:

Angel Flight and AOPA Australia have maintained that the ATSB report produced defective findings that were underpinned by false outcomes which were derived from wildly inaccurate and manipulated statistics, calling for the report’s withdrawal.

During the inquiry, the ATSB admitted that it had not interviewed any pilots in arriving at it’s conclusion; that community service flight pilots were operating under significantly more stress than pilots in other sectors.  The ATSB went on to admit that it had conflated findings from an unrelated survey to support it’s allegations of pilot pressure and stress.  When pressed on this issue, the ATSB argued that if it had surveyed or intervierviewd pilots specifically on the issue, they did not feel pilots would have given them honest answers.

Regarding the ATSB statistics, the investigator admitted that they did not have accurate data records and had based their report on estimated and modeled numbers, acknowledging that they did not include all Angel Flight’s undertaken during the statistical period used.  This modelling enabled the ATSB to produce a finding that alleged Community Service Flights to be 7 times more likely to be involved in a fatality, which sits in contrast to the reality that Angel Flight has experienced just two fatal accidents in 20 years spanning 40,000+ flights flown, which left the RRAT Inquiry panel questioning the statistical relevance of the ATSB’s claims.

And, the ATSB weren’t alone in their damning admissions.  CASA went on the record admitting that their legislative changes had no relevance to either of the two Angel Flight accidents, also stating that their changes would not have prevented either accident from occuring and would not stop similar accidents from happening again.

In view of the clear evidence given to the Senate RRAT Inquiry, which leaves no doubt as to the need to withdraw the ATSB report and CASA’s inappropriate legislative changes, it certainly raises serious questions as to how the TAAAF Chair, Mr Jeff Boyd, and it’s members could possibly have supported the ATSB and CASA at all.

Do Australia’s general aviation associations and bodies genuinely feel that it is appropriate or acceptable that the ATSB produce investigation reports based on manipulated data, conflated survey results – all without interviewing or surveying a single pilot or participant?  Its hard to imagine, but this is what the TAAAF have argued, which gives rise to serious quesitons.

Was the former CASA Chairman given a tap on the shoulder for support?  Was he called on to throw a lifeline to the ATSB and CASA?  Did the airline he works for bias his judgement?  Is the TAAAF statement supported by it’s members?  Does the TAAAF represent general aviation as it claims?

Over the past few days, AOPA Australia has reached out to the various members of the TAAAF, seeking to understand if each of the associations were in full agreement with the statement of support, which has revealed some telling facts;

According to the TAAAF letter to the Senate RRAT Inquiry, the association represents thirteen associations and bodies, claiming to be an alliance of the majority of Australia’s major aviation associations… these include;

  • The Royal Federation of Aero Clubs of Australia (RFACA)
  • Regional Aviation Association of Australia (RAAA)
  • Australian Helicopter Industry Association (AHIA)
  • Recreational Aviation Australia Limited (RAAUS)
  • Aviation Law Association of Australia and New Zealand (ALAANZ)
  • Aviation Innovation Centre
  • Australian Women Pilots Association (AWPA)
  • Australian Business Aircraft Association (ABAA)
  • Australian Certified UAV Operators (ACUO)
  • Antique Aeroplane Association of Australia (AAAA)
  • Australian Sport Aviation Confederation (ASAC)
  • Australian Association for Unmanned Systems (AAUS)
  • Australian Warbirds Association Limited (AWAL)

A brief telephone investigation by AOPA Australia revealed that the majority of the TAAAF membership was either unaware, in disagreement or seeking to disassociate themselves from the statement of support.

These are our findings:

TAAAF asserts that it represents 13 industry associations and bodies:

  • Three (3) of the thirteen (13) member associations are entirely unrelated to manned general aviation in Australia;
  • Two (2) of the thirteen (13) member associations were unavailable for comment;
  • Five (5) of the thirteen (13) member associations were found to be disassociating themselves with the TAAAF statement of support, but did not want to indicate if they had agreed to its publishing;
  • One (1) of the thirteen (13) member associations was not aware that they were a member of the TAAAF and did not understand why their association had been included in the communication;
  • One (1) of the thirteen (13) member associations was aware of the statement, but did not want to provide any statement;


  • Just two (2) of the thirteen (13) member associations stated that they were in full agreement with the TAAAF statement;

The above results, appear to contradict the TAAAF statement that it’s membership ‘fully-supports’ the ATSB & CASA, and if correct should be the basis on which the letter should be withdrawn, as it could be considered a gross misrepresentation and an attempt to mislead a Senate Inquiry, leaving significant doubts as to the integrity of the TAAAF and their claim to represent the general aviation industry.

Withdrawn or not, I have no doubt that there will be many pilots shaking their heads, all wondering as to the motivations of each of the industry associations involved.

Sadly, it does appear that the ATSB, CASA and now the TAAAF all share something in common.

Something wrong here.

Senate inquiry announced into Australian Transport Safety Bureau’s report on Angel Flight

The debris from an Angel Flight crash at Mount Gambier in 2017 that killed three people. Picture: Tom Huntley
The debris from an Angel Flight crash at Mount Gambier in 2017 that killed three people. Picture: Tom Huntley

A Senate committee has launched an inquiry into the operations of the Australian Transport Safety Bureau, following its report on the fatal crash of an Angel Flight service in 2017.

The final report, released last week, found Angel Flight had a fatal accident rate seven times that of other private pilot operations, after two triple fatality crashes in six years.

In both accidents, the pilot was found to have taken off in conditions they were not qualified to fly in, which ultimately led to them crashing and killing all on board.

The crashes have prompted a new safety campaign by the ATSB targeting private pilots with the slogan “don’t push it, don’t go”.

It was also recommended that Angel Flight consider booking seats on commercial flights for its clients because of the excellent safety record of Australia’s airlines.

Angel Flight CEO Marjorie Pagani spoke out against the report, suggesting it contained no useful information or guidance for them, and that it was ignorant to suggest commercial flights were an option.

Crossbench Senator Rex Patrick was also highly critical and said his concerns were shared by other senators on the Committee for Rural and Regional Affairs and Transport.

“There were concerns among a number of Senators about the findings of the report, not so much in relation to the forensic analysis of the accident at Mount Gambier, but the report as it covered Angel Flight,” Senator Patrick said.

“Firstly, there are questions over the statistical analysis and the committee rightfully wants to hear Angel Flight’s perspective, and secondly the claims that community service flights can be replaced by commercial sector flights was only supported by a narrow data set and in fact ignored some realities.”

At this stage a single public hearing has been scheduled for September 4, at which the committee will hear from Angel Flight, the ATSB and the Civil Aviation Safety Authority.

Senator Patrick said submissions to the inquiry would be accepted and encouraged pilots and former clients of Angel Flight to do so.

He denied his vocal support of Angel Flight and public criticism of the ATSB demonstrated bias ahead of the inquiry.

“The way this works, is Senators reach a particular threshold that might cause them to call an inquiry, and from that time onwards they remain open to all perspectives,” said Senator Patrick.

“We are all open to the information that will be presented.”

ATSB chief commissioner Greg Hood said they “noted the inquiry” had been established and were confident in their evidence-based investigation.

“The ATSB welcomes the opportunity to explain its methodologies and the findings of this comprehensive and thorough investigation,” said Commissioner Hood.

Senate Submissions

Submission 1 – Mr Howard Hobbs-1

Submission 2 – Mr Shaun Aisen

Submission 3 – Mr Allen Hilton-1

Submission 4 – Civil Air Australia

Submission 5 – Mr John Raby

Submission 6 – The Australian Aviation Associations’ Form

Submission 7 – Mr Alexander Reith

Committee Secretary
Senate Standing Committees on Rural and Regional Affairs and Transport
PO Box 6100
Parliament House
Canberra ACT 2600.                  

Australian Transport Safety Bureau (ATSB) inquiry submission, an open email. 

Dear Senators,

I wish to support those submissions that I’ve read in regard to the ATSB by Mr. Aisen, Mr. Hobbs and of Mr. Hilton, and contribute additional opinion. 

Obviously the ATSB’s report into the Mt. Gambier accident is flawed and serious questions must be raised as to the motives or reasons for such a poor report. 

Professional and private aviation industry personnel have been following the ATSB’s reports for many years, but more particularly since it became an independent Commonwealth corporate body in 2009. 

Many, and probably the great majority, now have little or no confidence that the ATSB is capable of producing reports of value. In reality the reverse is true, the Mt. Gambier report, as an example, can only confound those who would look for answers and constructive suggestions that might lead into new avenues for the safety of flight. 

Whilst I concur completely with the thoughtful and detailed analysis by the submitters as noted, my concern is to respectfully ask the Senators to consider the broader context and the failed model of governance as represented by the independent ATSB. 

Similarly the Civil Aviation Safety Authority, independent since 1988, has failed to live up to it’s legislated duty to provide, quote, “clear and concise” rules and regulations (see illustration). The result is the most astonishing demise of a once flourishing industry of General Aviation (GA). Though my critique of CASA may not be directly germane to the performance of the ATSB, it does provide a clear demonstration of a failure of governance, by that of the relatively unaccountable independent regulator. 

This points directly to the need for a greater degree of Parliamentary control. Without direct and constant accountability to a Minister, or some other Parliamentary body of responsibility, then it is apparent and unsurprising that such bodies can stray from their legislated purpose. 

Certain settings have clearly influenced the actions of such bodies, the fact that, unlike a Government Department, they can be sued, has contributed to the CASA attempt to micro manage, to control to an extreme degree. In addition, CASA has caused Parliament, inappropriately, to migrate practically all the rules into the criminal code with strict liability as the standard of proof to ensure maximum prosecution success. This of course has driven incident reporting to very low levels. Who wants to own up and then bear a criminal conviction with all that entails including loss of international travel ability? The fear of reporting mitigates against safety. 

The CASA attempt to ‘straight jacket’ the aviation industry into an inhuman model of perfection has caused the extraordinary decline of GA that has become so evident. It has failed to produce a safer level in flying. It is easily arguable that flying is less safe because of incompetent administration and rule making. 

It is my belief, as a senior instructor and experienced commercial pilot and former GA business owner operator, that the severe punishments available to authorities for even the most minor of infringements (and for some that don’t even exist in the USA) have a deleterious psychological effect on pilots. By exacerbating stress levels this can go some way to explain illogical actions. If we can say the Mt. Gambier accident was as a result of illogical decision making then I will argue that stress levels and the loss of adrenaline are factors that should be taken into account and explored thoroughly. I have witnessed these phenomena, and have been personally subject to same, as have practically all pilots to some extent. Even before flight loss of adrenaline can cause extreme weariness and loss of clear and timely decision making. 

As others have rightly stated, the Mt. Gambier report deals at length with the operations of Angel Flight and largely ignores the causal factors of the actual accident and possible future remedies to prevent similar occurrences. 

Remedies like the provision of portable synthetic vision which reduced weather related visual flight accidents in Alaska by 50% (Operation Capstone). 

Provision of flying schools and instructors to teach for the Instrument Rating, unhampered by CASA’s near impossible flying school paperwork and super expensive, unnecessary administrative structures could also have been noted for policy adjustment. 

Thanking you,
Sandy Reith 
Alexander C. (Sandy) Reith 

New flying school comparison:

Australia….Permit $50,000?+? Months or years to negotiate, various approved personnel. 

USA……….No permit, Instructor Rating & book $15.99. Start immediately. Better safety record. 

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