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Gympie Coroners Report released today

Gympie Coroners Report released today, and the report is as follows:

Coroners Inquiry – Gympie Replica Supermarine Accident

In part, Coroner said about the Supermarine accident at Gympie:

CASA

It is clear that CASA had investigated Mr O’Sullivan prior to the inquest in relation to his provision of false information for other aircraft, but there appears to have been little communication with RA-Aus.

It is recommended that CASA review its policies and procedures to ensure that any adverse findings, or indeed any issues arising from CASA investigations relating to pilots who are also members of recreational aviation associations, are communicated with those associations.

This will highlight for those associations any potential issues and enable them to assess any safety implications for their association. It will then place them in a position of having constructive knowledge of events and circumstances to enable them to take appropriate action if required.

Also, whilst it is accepted that there are limited resources, it is recommended that CASA review its delegation to RA-Aus in terms of what is expected of them in screening and auditing aircraft documentation, which is submitted by its members. Random audits by RA-Aus would be appropriate to assist in the deterrence aspect, but further funding needs to be provided for this purpose, or CASA should consider undertaking such audits itself.

RA-Aus

It is vital that if RA-Aus is to continue in their current role with limited resources, they must rely on the integrity and honesty of those seeking to have registration under its auspices. There must therefore be a clear deterrent to anybody who intends to circumvent the systems of safety by wrongly registering an aircraft.

As such, I recommend that RA-Aus take the strongest possible action they can against Mr O’Sullivan and they should consider terminating his membership and cancelling all certificates and endorsements currently in his possession.

I also recommend that within their limited resources, RA-Aus implement a more effective screening and auditing system to randomly check information such as weight calculations and other information provided for registration.

RA-Aus provides a valuable service to police and coroners by investigating recreational aircraft acidents involving their members and aircraft registered with them, when the ATSB chooses not to investigate.

Unfortunately, this coronial investigation was affected by RA-Aus’ failure to finalise their investigation into this matter. I therefore recommend that better procedural processes be established by management to ensure that all investigations are finalised within a timely manner in the future.

Also, an allegation arose in this inquest of RA-Aus altering an investigator’s report into a different matter.

RA-Aus submitted, and it is accepted, that their investigators are contracted by them to provide them the information to furnish an organisational report. Management consults with investigators to amend their findings where they do not align with RA-Aus’ view.

In order to uphold the public’s confidence into the future, it is recommended that such consultation between RA-Aus as an organisation and their investigators be recorded and transparent.

Where agreement is not reached, consideration should be given by RA-Aus to finalising a report and annexing the investigator’s report, including areas where there are distinguishing aspects.

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