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2013 Coroner Finding + Press Reports

The Coroner’s finding,  was on 4th october 2013 – nearly 5 years after the event.


Hemple Inquiry:

On in Brisbane today, with Barrister Ian Harvey present to “protect” CASA. This is the Barrister who was “Counsel Assisting” at the Lockhart River Inquest.

And below is the information relating to this case.

Hempel – Summary CASA Show Cause etc


Transcript for Australian Story:

The Men Who Fell To Earth – Transcript

PROGRAM TRANSCRIPT: Monday, 24 June , 2013

KARINA CARVAHLO, PRESENTER: Hello I’m Karina Carvalho from ABC News in Brisbane. Tonight’s Australian Story is about a fatal plane crash off South East Queensland five years ago. A young woman, Samantha Hare, arranged the flight as a surprise for her partner. In the pilot’s seat was a colourful, well known aviator, Barry Hempel. What she didn’t know was that Mr Hempel had been stripped of his commercial pilot’s license, and that was by no means all. This is Samantha Hare’s story.

MARTIN KEOGH, FRIEND: Ian did like to live an adventurous life but he wasn’t stupid about it if you know what I mean. If he thought it was too risky he wouldn’t actually do it. He’d just go, “No. I’m not doing that.”

SAMANTHA HARE: I bought him a joy flight for his 35th birthday.

MARTIN KEOGH, FRIEND: He said this is the best present I’ve ever received, he was beside himself. He loved it. He absolutely loved it.

SAMANTHA HARE: He wanted to do it immediately. He rang up the next day and he booked it in for the Sunday coming. So it was um, yeah, he was, he was totally, totally thrilled. Mmm.

JEMMA HARE, SISTER: I remember earlier that day Ian just so excited and he was yelling, saying, “Yeah, I’m going on a flight! I’m going on a flight!” He thought it was the best present he’d ever been given.

JOHN JONES, CIVIL AVIATION SAFETY AUTHORITY INVESTIGATOR 2003 – 2010: There was primarily a joy flight but also with a bit of adventure, with loop the loops in it towards the end over water, somewhere in the vicinity of about an hour. That was the third flight of the morning.

SAMANTHA HARE: I met Ian in November 2005 and we were together for a little under three years. Ian had come out from England. I was sitting on the steps outside of work and this man walked up to me and he basically asked me out.

JEMMA HARE, SISTER: He was just captivated by her I guess and really wanted to get to know her. And when he did, he was just from the very start just completely in love with her. He was an animator and he created computer games.

BRUCE HARE, SAMANTHA’S FATHER: I was very happy that Sam had found somebody who had a work ethic, who loved her very much, and I thought this is great, she’s on a a good timetable here, get married and have a family.

SAMANTHA HARE: He knew how to love, he knew how to um make me feel beautiful.

(Photos from travelling)

SAMANTHA HARE: Ian and I were both very into travelling. Whilst we were in Cambodia Ian saw a helicopter taking off and he said to me, “Oh Sam, do you reckon that we could do that?” I just looked at him and I went “Ian there is no way we are going up in a helicopter today in Cambodia.” He understood, but you could see the disappointment. It was like a seed in my mind when his next birthday came up, I was like, “Yeah I this is what I want to do for him.”

MARTIN KEOGH, FRIEND: Back in Brisbane Sam pulled me aside and said, you know, “What do you reckon about this for his birthday present?” and I went “Oh he’d love it.” Samantha showed me the Hempel’s Aviation website at Archerfield Airport. Ah, in there it actually had listed, you know, all pilots have got pilots licence, are fully accredited by CASA and all that sort of stuff. So I thought straight away “Yeah that’s pretty good” and then when Sam told me that she’d actually rung Archerfield and Archerfield had recommended this company to do it, I mean how much more due diligence can you do other than that?

SAMANTHA HARE: I didn’t feel right to book over the phone. I wanted to go out and see where I was buying this from. When I arrived there was no point there where I thought that this was dodgy in any way.

MARTIN KEOGH, FRIEND: So myself, Sam and another friend, Adam, we all went thirds in the gift for him.

(Footage from Channel Nine news)
CHANNEL NINE REPORTER: If was capable of taking to the air, Barry Hempel’s probably flown it…

PAMELA AYSON, BARRY HEMPEL’S SISTER: He was the national aerobatic champion back in the ‘80s

(ABC News, 1992)
ABC REPORTER: Brisbane pilot, Barry Hempel, has completed the first major commemoration of the Hinkler centenary.

PAMELA AYSON, BARRY HEMPEL’S SISTER: And then there was the Hinkler, and also the Sir Charles Kingsford Smith re-enactment. One of the aircraft that he owned was a Russian MIG fighter. He also used to do a lot of air shows and display work. And what a lot of people don’t know is that many times when Barry was asked to perform at the air shows, whatever fee that he received a lot of that was donated to the Royal Flying Doctor service.

JOHN JONES, CASA INVESTIGATOR 2003-2010: He was very much an institution and so there was a degree of star factor that surrounds someone like that that’s quite a legend. He had at least 28,000 hours flying experience so he’d done it all.

SAMANTHA HARE: We woke up early. I took him to the airport. Ian was really, really nervous. And I just thought, well, that’s normal um in going up for your first time um and doing aerobatics. And I wish that I had’ve asked him more about like the reasons for why he was so nervous. I went out to the tarmac with Ian and I too lots of photos of him. Barry told him to empty his pockets and he was told he could take his camera up, a tiny little camera that he had. They took off. And I waited in the office for him to come back. And then when it was nearing the time for him to come back I um went out onto the tarmac. And I sat there, and I sat there, and I sat there, and they weren’t back.

JEMMA HARE, SISTER: I got this call from Sam. I could tell that it was, it was serious. And she just said to me, “Jem, can you come here ’cause he hasn’t come back and I’m really scared.”

SAMANTHA HARE: And then there was a phone call from the media.

JEMMA HARE, SISTER: I heard them say that it had gone down um and that it had nosedived or something around those lines.

(Channel Seven News, September 2008)
CHANNEL NINE REPORTER: Nine boats and three helicopters formed a line sweeping the sea for any sign of the missing aircraft.
WITNESS: It looked like he was finished what he was doing and heading back North but then he pulled a big loop again and then just disappeared

SAMANTHA HARE: I knew that he was gone. I knew. There’s no way that you can survive hitting the ocean um in a plane. Like it’s just, yeah, because yeah. So yeah. And that’s when my, yeah, my whole life turned upside down.

(Channel Nine News, September 2008)
CHANNEL NINE REPORTER: Police attended the Archerfield hangar late this afternoon where shocked staff and friends had begun to gather.

(ABC News, September 2008)
ABC REPORTER: A propeller blade has been recovered but hopes of finding the men alive are fading.
BILL HEMPEL, BARRY’S FATHER: In this case, I’d say, it doesn’t look good.
MICHAEL LAWRENCE, HEMPEL’S AVIATION CHIEF PILOT: Barry is a hero and a mentor to everyone. He really is one of the very greats.

PAMELA AYSON, BARRY HEMPEL’S SISTER: Barry was one of Australia’s most experienced aviators. And for that crash to have occured, it must have been something unforseeable to him.

LYNN LOVELL, IAN’S MOTHER: The plane had gone down and they didn’t know Ian was. We had this like vision that he had marooned on a, one of these little islands with all these trees waiting for someone to go and pick him up. And that’s what we clung to.

(Channel Seven News, September 2008)
CHANNEL SEVEN REPORTER: The search continued until last light. It will resume tomorrow.

MARTIN KEOGH, FRIEND: That was a terrible night, they didn’t even know where the plane was.

(Channel Nine News, September 2008)
CHANNEL NINE REPORTER: Late today water police divers began a search of Jumpin’ Pin where the Yak is thought to have crashed.

MARTIN KEOGH, FRIEND: The next day, the Gold Coast Water Police rang Sam and said “Listen we’ve found it. Do you want to come down?”

SAMANTHA HARE: I just remember this real sense of relief that they’ve, they’ve found Ian, I’m going to have him home. And then I got a phone call probably about half an hour later and I was told by someone from the police that it seems that the pilot didn’t have a licence. And I remember just falling to the ground and yeah and like to this day, I guess that’s kind of where all this has started.

LYN BRYANT, SAMANTHA’S MOTHER: How are you supposed to know from this that Barry Hempel doesn’t have a licence? This man was flying under the banner of having a commercial licence.

SAMANTHA HARE: I don’t understand how he was able to get away with something so public, advertised to the public.

LYN BRYANT, SAMANTHA’S MOTHER: If Barry Hempel didn’t have a commercial licence. He was not supposed to fly commercially, then everybody should know that. There should be some avenue where people know that.

JOHN JONES, CASA INVESTIGATOR 2003-2010: When I heard about the fatality it was a shock. But having had previous dealings with Mr Hempel, I couldn’t help but feel that in some ways something like that was always likely to occur because of the nature of the breaches he’s previously committed and I’d taken him to court over. Culminating in convictions and fines imposed on Mr Hemple and the company.

(Channel 10 news, Sept 2008)
PAMELA AYSON, BARRY HEMPEL’S SISTER: It was quite incredible the respect shown for Barry at the funeral. What really moved me and the family were the number of pilots, which turned out in the uniforms for the airlines they currently represent, and they were all trained by Barry. And that was a very moving scene to see.

SAMANTHA HARE: Ian’s parents actually arrived at that time as well. They had to come from England.

LYNN LOVELL, IAN’S MOTHER: Sam was absolutely devastated. She was so supportive. You wanted to hug her up and keep her in cotton wool because she was just so fragile.

SAMANTHA HARE: We had a memorial for him at Stradbroke Island.

(Images from memorial ceremony)

SAMANTHA HARE: John Jones was the CASA investigator of the plane crash.

JOHN JONES, CASA INVESTIGATOR 2003-2010: Starting from 2003, there was a series of investigations into the aircraft operated by Barry and just the way they were maintained. And it was obvious that for about five or six years, Mr Hempel did not have medical clearance to be flying.

BARRY HEMPEL: You know, I think if I had to give up flying I’d you know, probably might as well turn into a vegetable or something.

JOHN JONES, CASA INVESTIGATOR 2003-2010: He would go to air shows and offer joy flights. At times he was carrying anything up to a dozen people without maintenance on the aircraft and without a medical clearance. So that all formed part of the prosecution ultimately against Barry. He was fined in the vicinity of $16,000 plus the good behaviour bond for three years. Separate to the prosecution, CASA took administrative action to remove him from any position of responsibility within his own company and on top of that, his commercial and transport carrying licences were withdrawn from him. But a conscious decision was made to leave him with a private pilot’s license.

REPORTER: Did that surprise you?

JOHN JONES, CASA INVESTIGATOR 2003-2010: It surprised me yes, but in my role as an investigator I had very little input into decisions made at that level.

LYN BRYANT, SAMANTHA’S MOTHER: He had a private licence which means that he could crash the plane into any houses. To me he’s still…


LYN BRYANT, SAMANTHA’S MOTHER: A danger to the public. So why would CASA give this man back his licence?

JOHN JONES, CASA INVESTIGATOR 2003-2010: As a result of the fatality a fresh investigation started. It was initially dealt with by the Queensland Police. CASA got involved looking into what may have been the circumstances leading up to the crash. There’re number of issues that we were looking at, you know, whether it was perhaps suicide, whether it was a mechanical problem, whether it was just human error, whether there were medical problems. Because it wasn’t obvious and perhaps because the aircraft wasn’t recovered.

SAMANTHA HARE: From the very beginning of when I lost of Ian, nothing seemed to unfold the way that you would expect it to unfold when it came to the investigation. The plane was only 20 metres under water. They knew exactly where the plane was, they were able to recover Ian and Barry Hempel. But nobody was willing to actually raise it.

BRUCE HARE, SAMANTHA’S FATHER: We were told that it was going to come up eventually, and then they said, no, there’s no evidence, evidentiary value for the plane coming up, so it’s not going to come up now.

LYN BRYANT, SAMANTHA’S MOTHER: Marty and Sam basically worked, writing letters, contacting local members, trying to you know do all this work. They’d ring every week, “Is the plane coming up?, is…” “No, no, no, no.”

JOHN JONES, CASA INVESTIGATOR 2003-2010: It certainly would have helped to have recovered the aircraft as opposed to divers diving on it and trying to make assessments of possible reasons for it to have crashed. Such as loose objects that could have interfered with the foot controls of the aircraft that may have then jammed and then caused the aircraft to crash.

PAMELA AYSON, BARRY HEMPEL’S SISTER: Now the passenger on that day had a camera. And it was supposed to have been strapped to his wrist. The camera was never recovered. Did the camera dislodge and become stuck under the controls and Barry lost control of the aircraft? We’ll never know.

JOHN JONES, CASA INVESTIGATOR 2003-2010: Unfortunately there was no agreement made, or even a cost-sharing basis of the recovery of the aircraft and unfortunately it’s still just remains there as a dive wreck to this day.

SAMANTHA HARE: I realised the plane’s not going to come up. So what needs to happen next?

LYN BRYANT, SAMANTHA’S MOTHER: Sam decided that she wanted some justice for Ian. She talked to his parents and they decided that they would start a civil case.

KEN FLEMING QC, FAMILY BARRISTER: Samantha has been through a lot of things including the fact that she was the person who bought the ticket thinking that she was going to um give her fiancé um something very special. And of course it turned out the way it did. She’s entitled to pursue civil action which she’s doing, and that’s where any monetary reparation comes from.

(Channel 10 news)
CHANNEL TEN REPORTER: A coroner’s heard that pilot Barry Hempel could be also be a dangerous cowboy.

MARTIN KEOGH, FRIEND: It was a two week inquest. The coroner told us what the coronial investigation was out there to achieve was not to accuse people of wrongdoing per say but to put things into place so these sort of things won’t happen again as a prevention.

(ABC News)
ABC REPORTER: During the inquest, Barry Hempel has been described as a renegade and a liar.

KEN FLEMING QC, FAMILY BARRISTER: There’s truly a smorgasbord of issues and um it’s going to take a lot for the coroner to get his mind around the whole lot.

SAMANTHA HARE: What was really evident was Barry’s medical history, and really that only became clear to me from the inquest.

JOHN JONES, CASA INVESTIGATOR 2003-2010: Back in about May 2001, Mr Hempel had received a belt to the side of the head from a hangar door at Archerfield aerodrome. As a result of that his medical was suspended and ultimately cancelled for a number of years.

(ABC News)

ABC REPORTER: The inquest heard Hempel had two seizures in 2002 which resulted in ambulance call outs.

JOHN JONES, CASA INVESTIGATOR 2003-2010: A former paramedic came forward and he recalled attending his place where he was having a fit or a seizure.

SAMANTHA HARE: They actually had to drive the ambulance onto his driveway so he couldn’t drive his car away and fly a plane.

BRUCE HARE, SAMANTHA’S FATHER: They contacted his doctor who said give him give him freedom to do what he wanted to do on that day, whether it’s to go and fly planes or whatever.

SAMANTHA HARE: John Jones then provided that ambulance report to the medical team at CASA

JOHN JONES, CASA INVESTIGATOR 2003-2010: It’s still a possibility that the fits that Mr Hempel had may have had a bearing. I believe, when they examined his body there was no indication of injuries consistent with being conscious at the time of the accident. There were no broken wrists, and that is apparently an indicator to suggest a bracing before an accident. That may have been an issue still at the time of the fatality, and again it’s one of the issues that the coroner would be looking at.

(ABC News)
ABC REPORTER: CASA approved Neurologist, Dr Ian Maxwell, examined the pilot in 2005.

SAMANTHA HARE: From the information that’s been provided, it seems that he had um numerous fits and that he would’ve been diagnosed epileptic. Or he should have been but he wasn’t.

(Channel 10 News)
CHANNEL TEN REPORTER: The doctor said he wasn’t aware of an ambulance report. He said that if he had seen the report he would have recommended cancelling his licence. As it was, Dr Maxwell took the veteran pilot’s word that he had no symptoms of epilepsy.

BRUCE HARE, SAMANTHA’S FATHER: There’s about three or four doctors, wasn’t there? They brought up the relationship of some of those doctors to Barry Hempel. Really more or less indicating that they couldn’t be completely objective because Barry had taught some of them to fly and had a sort of relationship with them. Ah so, why didn’t CASA have independent doctors?

KEN FLEMING QC, FAMILY BARRISTER: Every um, possible step should be taken to um discover the pilot’s real state of health, rather than perhaps a subjective one.

(ABC News)
ABC REPORTER: The coroner flagged that he could make a finding that a pilot’s medical records be made available on a centralised database. That way, organisations like CASA could conduct thorough background checks.

SAMANTHA HARE: CASA knew all of that information. If they had’ve actually consulted with each other they would’ve known all of Barry’s background and history.

JOHN JONES, CASA INVESTIGATOR 2003-2010: He wasn’t a protected species. He was subject to regulation. He had breaches imposed and restrictions placed on him and his removal from the company. He was subject to closer scrutiny. Unfortunately Mr Hempel was one of those that no matter what, no matter how close the scrutiny, he was always in my mind, in my own opinion going to do what he did best and that was to fly. Now whether that was whether with a license, or with the approval of CASA, he was always going to do that and there’s nothing and no one would stand in the way of him doing that. It was his love, it was his life.

SAMANTHA HARE: At the inquest a representative for CASA, came up to me and basically said, “Sorry for your loss.” And I said, “Well, I think we have a number of changes um that’ve been brought up in this inquest, that need to happen, so somebody else doesn’t experience a loss like this again.” And he basically said to me, “What changes?” He didn’t seem to think that there was any changes that needed to occur. That was really difficult to get my head around because CASA had suspended Barry’s commercial licence, but at the same time, they could have cancelled his private licence. They could have informed the aviation community at large that his commercial licence had been cancelled. They could have arranged independent assessments in relation to his medical condition and they could have monitored his website. If CASA had of put any one of those safeguards in place, Ian would still be alive.

(Sitting with family)

SAMANTHA HARE: It feels like there’s actually no body to make sure that there is actually changes made within CASA.

BRUCE HARE, SAMANTHA’S FATHER: Well Ironically, that’s the role of CASA isn’t it?…

MARTIN KEOGH, FRIEND: As part of the inquest, we were offered the chance to inform the coroner of what we’d like this inquest to achieve.

SAMANTHA HARE: That if a pilot has sufficient violations or other reasons for having his commercial licence revoked, then his private licence should also be revoked.

BRUCE HARE, SAMANTHA’S FATHER: Then there is no confusion. If the mans in the air, he’s in the air illegally.

MARTIN KEOGH, FRIEND: We all got together and thought “OK these are some of the outcomes that we’d like to see.”

BRUCE HARE, SAMANTHA’S FATHER: CASA, they are miss monitoring the websites that are full of lies. It was her chance and our chance I guess to put forward recommendations that were practical and logical which could look after the safety of the public at large.

MARTIN KEOGH, FRIEND: Sam got up at the inquest and announced what we’d like.

KEN FLEMING QC, FAMILY BARRISTER: I watched the coroner while Samantha was speaking and he was quite moved by the whole thing. Um he, he became quite emotional about it and I think that to see somebody who had been through what Samantha had been through, and then to hear her was very valuable for both the coroner and Samantha, and perhaps Samantha’s family as well. That hasn’t finished yet. the coroner hasn’t handed down his findings, and civil actions have been commenced against various people.

LYN BRYANT, SAMANTHA’S MOTHER: I think that she’s an incredibly strong woman and she’s worked very, very hard to get through this. But I hope that this inquest will give her a chance to move on with her life because that’s what she needs now. She needs to move on.

LYN LOVELL: I’ve always called her my daughter because that’s what she would have been. She’s got a special place in my heart. I’d love her to find someone who can look after her, the way Ian would have looked after her. Ian wouldn’t want any different, he wouldn’t.

The Civil Aviation Safety Authority says it had no knowledge and had received no reports or information that Mr Hempel was conducting unauthorised flights after CASA’s cancellation of his commercial pilot licence in 2007

The Air Transport Safety Bureau says that after a review it has committed, despite limits on its resources, to investigate all fatal accidents involving powered aircraft with a civil registration, regardless of the nature of the operation.

The Coroner is expected to deliver his findings on the accident in August.


The latest Shane Urqhart questions and answers:

These follow the Hemple coronial in Brisbane


Just some more Hemple stuff:

Old 21st Jun 2013, 19:04   #2132 (permalink)
Join Date: Nov 2011
Location: Australia
Age: 42
Posts: 347
Hmm..any bets on when we’ll pass 500k??

Getting close. By midnight. If not by noon Sat definitely.

This story has just been posted on the Hempel thread.
Woman sues doctors over partner’s death during joy flight crash with pilot Barry Hempel | News.com.au

Australian Story ad
The Men Who Fell To Earth | Australian Story | Monday 24 June at 8pm, ABC1 – YouTube

Last edited by halfmanhalfbiscuit; 22nd Jun 2013 at 03:59.

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Unread 22nd Jun 2013, 02:39   #2133 (permalink)
Join Date: Jul 2001
Location: Australia
Posts: 1,784
Australian Story this Monday night on ABC TV for Hempel, once again CASA’s efficiency, effectiveness and diligence will be on display.
Tootle pip!!PS: Sunfish, what elsecan be done?? People should cast their minds back to the fate of the old Department of Customs and Excise, when it became too big a public embarrassment for the politicians.Some of those inquiries I mentioned over many years were Royal Commissions.Reviewing the SMABC submission to Miller, I don’t think there was one reservation or forecast that was not proved entirely justified or accurate by the Pel Air Report.

Last edited by LeadSled; 22nd Jun 2013 at 02:42.

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Some pprune notes for a read:

Old 4th Oct 2013, 15:05   #607 (permalink)
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A ‘register’ of unfit people, or a ‘hit list’ in the hands of CASA give me cause for concern. But then again I don’t like the new centralized digital medical records either.Of note also is the failure to recover the wreckage after The Coroner requested it be done soin a timely manner. That has some parallels with the Lord Howe Island matter.The concept of a new engine and prop mitigating the conclusion that no mechanical failure is likely flies in the face of some US studies, (I can’t remember where I read it), that put the most likely time for an engine failure as just after major overhaul.

I believe The Coroner got it right in general and one should include the word ‘culture’ in any dealings with our regulator. Any ‘inter agency complexities’ should also consider this.

Last edited by Frank Arouet; 4th Oct 2013 at 15:07. Reason: Yank spell checker/ have it your way then!

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Old 4th Oct 2013, 15:25   #608 (permalink)
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Look up your doctor here:Australian Health Practitioner Regulation Agency – Registers of Practitioners
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Unread 4th Oct 2013, 15:44   #609 (permalink)
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John Hutton, Coroner.

The world is still deceived with ornament.
In law, what plea so tainted and corrupt,
But, being seasoned with a gracious voice,
Obscures the show of evil?

Cherry picked; (alas, with no hidden chanteys) but pertinent. Better men have lost much more, for much, much less. Now, was this all ‘unfortunate’ or:-

He had a contumelious disregard for aviation regulations and the law and he had an extensive history of offences and breaches. I attach hereto a schedule which is self-explanatory.
As shown by the Schedule of this decision, Mr Hempel had a long and extensive history, dating back to 1968, of breaching flying regulations.
His group of companies, including Hempel’s Aviation Pty Ltd, also had an extensive history of breaches of both administrative and flying regulations.
Given the above it goes without saying that he was well known by CASA and had had at one stage or other, inter alia, his Chief Flying Instructor delegation as an Approved Testing Officer (“ATO”) withdrawn, his ATO delegations to issue aircraft endorsements removed and various other ATO delegations cancelled. Mr Hempel’s licences, had, at various times, been suspended or cancelled.
“well aware that Mr Hempel was a pilot who flew with a total disregard for the safety regulations enacted to protect the public, passengers and the aviation industry generally.”
The evidence at the Inquest gave an impression of a man who believed he was “above the law” so to speak.
It could be argued that the number and nature of Mr Hempel’s breaches and the fact that many were repeated breaches indicated that Mr Hempel would probably never comply with safety regulations. In the light of the extensive history of breaches it is indeed extraordinary that he was left with even a Private Pilots Licence
What is truly perplexing about this case is that Mr Hempel had any kind of licence at all.
Given the litany of Barry Hempel’s breaches, one is left wondering why CASA allowed him to continue flying notwithstanding his ability to fly, but given his history of breaches, the question arises as to whether he was a fit and proper person to hold any kind of aircraft licence

Or; just plain (plane) protected ??.

No man is above the law and no man is below it; nor do we ask any man’s permission when we ask him to obey it. (Theodore Roosevelt).

Avmed tomorrow, there are some questions methinks;…..

Last edited by Kharon; 4th Oct 2013 at 15:49.

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Unread 4th Oct 2013, 16:09   #610 (permalink)
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casa involvement in Hemple

Careful reading of the Coroner’s finding reveals some gems:

    Counsel Assisting: Ms Karen Carmody
    Samantha Hare & family of Ian Lovell: Mr Ken Fleming QC i/b Kerin Lawyers
    Civil Aviation Safety Authority: Mr Ian Harvey
    Dr Sheahan, Dr Lam & Dr Spall: Mr P Hastie i/b Ashurst
    QBE Insurance: Mr A Katsikalis i/b Carter Newell
    Mr Craig: Mr A Mansfield
  2. The Yak was designated as a ‘limited category aircraft’ in that the design manufacture and airworthiness were not required to meet the standards of the Civil Aviation Safety Authority (CASA). The Yak was regarded as a Warbird and as such it was less stringently operated and administered than normal passenger carrying aircraft.
  3. CASA schedule of regulatory action & criminal proceedings [45 charges/ proceedings] instigated against the late Barry Hempel for breaches of Aviation Legislation;
  4. Hempel’s Aviation Pty Ltd, also had an extensive history of breaches of both administrative and flying regulations;
  5. His Commercial Pilots Licence (Aeroplane), his Transport Pilots Licence (Aeroplane) and his Commercial Pilots Licence (Helicopter) had all been cancelled by CASA;
  6. CASA was, therefore, well aware that Mr Hempel was a pilot who flew with a total disregard for the safety regulations enacted to protect the public, passengers and the aviation industry generally;
  7. Mr Hempel was not authorised to take fee paying passengers;
  8. It became evident that no-one, other than Mr Hempel and CASA, knew what licence he held;
  9. Given the litany of Barry Hempel’s breaches, one is left wondering why CASA allowed him to continue flying;
  10. It was the evidence of the officers [QAS] that in their opinion, Barry Hempel had suffered an epileptic seizure [in 2002]. This was clearly marked on the report which was provided to CASA;
  11. At the inquest Dr Maxwell was shown the ambulance report in relation to the events of October 2002 which had been in CASA’s possession. He said this was the first time he had seen that document;
  12. Dr Maxwell said he had to rely upon that which Barry Hempel told him, and for the purposes of the report he was never supplied with the ambulance report by CASA. Had he been so supplied, he said he would never have recommended Barry Hempel’s licence be returned;
  13. In relation to a diagnosis of epilepsy, Dr Cameron was most emphatic, an AV-MED doctor must notify CASA then it’s up to CASA to consider the person’s licence;
  14. He replied – ‘Based on this report, I would still, if he was a pilot, I would say you can’t fly. I would notify CASA I would then do a neurological assessment an examination with EEGs and MRI et cetera.’
  15. Dr Cameron went on to say that it is up to the pilot to notify CASA as well. In summary, Dr Cameron said – ‘I don’t ground him. I say he can’t fly. CASA grounds him.’
  16. Notwithstanding his clinical suspicions, Dr Spall failed in his duty as an av-MED doctor to advise CASA that he had his reservations concerning Barry Hempel’s epilepsy and that he had in fact prescribed Tegretol to him.
  17. During the inquest it became apparent that Dr Spall was aware of at least two instances after the accident with the hangar door, which could have been put down as epileptic episodes, and he failed to communicate his concerns to CASA;
  18. Witnesses from CASA Aviation Medical Branch including Dr Tak Shum and Dr Liddell both agreed that CASA received a copy of the QAS report dated 29 October 2002;
  19. This document ought to have put CASA on red alert as to Barry Hempel’s ability to fly. It is unbelievable that CASA did not act;
  20. During the inquest it became obvious that CASA medical officers were cavalier in respect to the QAS reports of both 1 July 2002 and 29 October 2002, and notwithstanding the opinions of Dr Maxwell and Dr Cameron in relation to ambulance staff and paramedics generally, CASA medical officers chose to disregard the observations of trained paramedics;
  21. The fact that CASA did not test the truthfulness of Barry Hempel’s assertions and withdraw his licence after a due and diligent enquiry proved absolutely disastrous;
  22. A further disturbing aspect of the case is internally, CASA had been on notice as to Barry Hempel’s medical condition and that it required further investigation, and
  23. That notice had been included in a report provided to CASA by Mr John Jones, a CASA investigator;
  24. It is of concern that the Australian Traffic Safety Bureau (ATSB) chose not to investigate the crash;
  25. This concern is compounded by the fact that CASA commenced an investigation but does not seem to have concluded it and no formal or informal report into the incident has been provided to the inquest;
  26. It appears that the Queensland Police Service (QPS) is responsible for the investigation of Civil Aviation accidents/incidents when the ATSB does not attend;
  27. Whatever the complexities of an inter-agency investigation and the delineation of which entity had the responsibility for investigating an incident, it seems that, in reality, it fell between the cracks;

Recommendations Re CASA by the Coroner:

  1. That CASA consider immediately disseminating the names of pilots to the industry who have had conditions imposed upon their licence or had their licence suspended or cancelled. As it is a matter of some urgency, the dissemination should be by way of emails.
  2. That CASA consider immediately introducing a Register of Pilots which includes reference to licence suspensions and cancellations. That further dissemination
    Findings of the inquest into the death of Barry Hempel and Ian Lovell 16
    Findings of the inquest into the death of Barry Hempel and Ian Lovell 17
    should be by way of, a readily available entry on the CASA website in the form of the Register of Pilots, in the CASA briefing newsletter and the bi-monthly electronic magazine ‘Flight Safety Australia’.
    (a) The fact that the Register exists should be published as widely as possible and on an urgent basis so that all pilots, airports and related aviation industry members are alerted to its existence.
    (b) In the event that concerns are raised by CASA with respect to privacy or confidentiality requirements CASA should be referred to a range of entities which have long published such Registers.
  3. That when investigating a pilot’s medical fitness CASA should consider adopting the practice, in the event of becoming aware of an ambulance/paramedic attendance upon the pilot, of obtaining the ambulance/paramedic report and related hospital reports. Where relevant they should also speak to the author of such reports. Those reports should also be forwarded to that pilot’s Aviation Medical Examiner.
  4. That CASA give consideration to a review of the ‘culture’ within its Medical Unit of accepting medical information provided by pilots rather than being cautious, in particular with respect to pilots who are at risk of losing their licence.


The above is a summary of what casa was up to in the Hemple case – enough “….holes in the green cheese to line up again and cause a fatality….”

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