• The path of VH-YTM as the pilot positioned the aircraft for landing. (ATSB)
    The path of VH-YTM as the pilot positioned the aircraft for landing. (ATSB)

The Australian Transport Safety Bureau (ATSB) has recommended that Angel Flight clients should be placed on regular public transport (RPT) flights rather allow private pilots to fly missions.

The conclusion was part of an investigation report released this morning into the 2017 crash of a TB10 Tobago at Mount Gambier on an Angel Flight mission.

According to the ATSB, the pilot of VH-YTM was ferrying passengers from Mount Gambier to Adelaide in June 2017 when he took off into low cloud and poor visibility. The aircraft reached a maximum altitude of only 300 feet before it descended and struck terrain about a minute after take-off. All three on board were killed. The flight was VFR and the ATSB considered the pilot did not have IFR proficiency.

" ... the pilot took off in low-level cloud without proficiency for flight in instrument meteorological conditions," the report states. "Shortly after take-off, the pilot likely lost visual cues and probably became spatially disorientated, resulting in loss of control of the aircraft and collision with terrain."

Cameras at Mount Gambier airport and GPS tracks showed the pilot conducted a series of non-standard turns during his initial approach to the airport and that conditions were marginal.

Among its findings, the ATSB stated that Angel Flight's incident rate was "considerably more" than other private operations, that Angel Flight didn't have controls in place to address operational risks involved in community service flights and that CASA didn't have a system in place to differentiate between community service flights and normal operations.

"The ATSB found two aspects in particular likely contributed to this higher rate," the ATSB explained. "These were the potential for some pilots to experience perceived or self-induced pressure by taking on the responsibility to fly ill, unknown passengers, at scheduled times to meet predetermined medical appointments, often with an expected same day return; and the required operation to unfamiliar locations, and limited familiarity with procedures in controlled airspace (associated with larger aerodromes)."

The ATSB also slammed Angel Flight for not having placed the passengers on commercial RPT.

"It was identified that Angel Flight did not consider the safety benefits of commercial flights when suitable flights were available, the report states.

"While Angel Flight arranged and paid for commercial flights (18% of all flights) for capital city transfers, or when private pilots cancelled, it was estimated that nearly two-thirds of the private flights conducted for Angel Flight had a commercial regular public transport option available, which offered considerable safety benefits when compared to private operations.

In a media statement accompanying the reports, ATSB Chief Commissioner Greg Hood said that Angel Flight should use RPT as a first resort.

"The ATSB has issued a formal safety recommendation to Angel Flight Australia, recommending that it consider paying for commercial flights where they are available to transport its passengers," Hood said.

“This ATSB investigation showed that commercial passenger flight options are available for nearly two-thirds of the private flights organised by Angel Flight.

"Angel Flight could purchase tickets on commercial flights for two passengers for a comparable cost to the organisation to what they normally reimburse for the fuel costs of privately-operated flights. Taking into account other passenger needs, 30 to 40% of flights could be done using existing commercial flights.

Angel Flight responded to the safety concerns raised in the investigation by saying it considered it inappropriate for the ATSB to criticise them for not abandoning the model for which they were constituted.

"Angel Flight only consider[s] the use of regular passenger transport in two circumstances: if a private pilot is unavailable or cancels at short notice and flights are available, or if the flights are capital city to capital city.

"They are not, and are not required to be, considered other than as a back-up and for long distance compassionate flights."

In March this year, CASA instituted new restrictions on pilots conducting community service flights, which is currently the subject of legal action between Angel Flight and the regulator. The matter has also been listed for disallowance motions in both the Senate and the House of Representatives.

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