Australia: Angel Flight accident investigation highlights risks of community service flights

Last Updated: 2 September 2019
Article by Andrew Tulloch

In brief - ATSB says operators of community service flights should consider their operational risk factors and the safety benefits of suitable commercial flights

A recent Australian Transport Safety Bureau (ATSB) investigation into a fatal accident at Mt Gambier in June 2017 has provided an opportunity for the ATSB to highlight the increased risks associated with community service flights. However, the report has sparked a lively debate with operators.

In June 2017, the charity Angel Flight arranged to transport a passenger for medical treatment from Mt Gambier, South Australia to Adelaide. The Socata TB-10 Tobago aircraft took off as a private flight operating under visual flight rules. After reaching a height of 300 feet the aircraft descended and impacted terrain about 70 seconds after take-off, killing the pilot and both passengers, and destroying the aircraft.

ATSB findings on the Angel Flight crash

It was found that the pilot took off in low level cloud without proficiency for flight in instrument meteorological conditions. It was considered likely that the pilot lost visual cues and became spatially disorientated leading to loss of control of the aircraft and the collision.

The wider findings

Aside from the tragic accident itself, the ATSB took this as an opportunity to investigate the wider issues regarding community service flying.

The investigation found that community service flights conducted on behalf of Angel Flight Australia has substantially more reportable occurrences and fatal accidents per flight than other private operations, and the fatal accident rate was more than seven times higher per flight than other private flights.

The reason for this was suggested to be that community service flights are exposed to different operational risk factors when compared to private operations. For example, there is potential for the pilot to feel perceived or self-induced pressure by taking on the responsibility to fly ill and often unknown passengers at scheduled times to meet pre-determined medical appointments and a requirement to visit unfamiliar locations, such that greater risks may be taken.

It was also identified by the investigation that Angel Flight did not sufficiently consider the safety benefits of commercial flights when suitable flights were often available and in circumstances where at least two-thirds of such flights were of comparable cost when compared with volunteer costs.

It was suggested that Angel Flight should consider the use of suitable commercial flights as a primary option when arranging and paying for flights to assist financially disadvantaged people.

Safety recommendations and implementation of safety standards for community service flights

Angel Flight Australia is now seeking permission for all registered pilots to access an on-line course "Public Benefit Flying: Balancing Safety and Compassion", which had been developed in the United States. A similar Australian course is being developed.

The ATSB also issued a safety recommendation to Angel Flight to take action to consider the safety benefits of using commercial flights where available.

Furthermore, the Civil Aviation Safety Authority (CASA) has since mid-March 2019 implemented a new safety standard regarding the conduct of community service flights, including a requirement that flight notification identifying the flight as a community service flight be submitted to Air Services Australia. Further, pilots are now obliged to annotate in their log book that the flight was a community service flight.

Angel Flight's response to the report and its recommendations

In response to the report, Angel Flight has published a formal response in the media questioning the factual basis of a number of the findings and seeking to correct what it considers to be mistakes made in the report.
In relation to the recommendation regarding use of commercial flights, Angel Flight notes that normally there is a need to carry not just a patient but another family member and that medical appointments can often not be arranged around commercial flight timetables. This in many cases makes use of commercial flights either impractical or unreasonably costly.

Angel Flight notes that induction training safety management systems and a pilot mentoring programme had been implemented a year prior to the report and its recommendations but it was required to stop because of new CASA requirements.

Angel Flight criticised the ATSB statistical data that compared only the passenger-carrying flight sectors and disregarded the flights prior to or after the passenger-carrying sector. It is also critical of the use of only flight numbers rather than flight hours in the calculation. Angel Flight maintained this distorted the figures as it was not a proper comparison of like with like. (The ATSB has rejected that criticism and says the calculations of risk are correctly made.)

There was also criticism of the statistical basis of the ATSB findings in relation to "occurrences".

ATSB report should hopefully result in improvements to community flight safety

There is no doubt that Angel Flight and similar community service organisations have played a vital role in assisting those unable to afford or otherwise access commercial flights. It is hoped that their assistance will continue to be provided and that the debate and safety actions implemented following this report will see those services continue but with increased safety for all.

Andrew Tulloch
Aviation
Colin Biggers & Paisley

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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