Coroner: Fatal crash plane owner showed ‘little empathy’
A CORONER has issued a scathing rebuke of a skydiving operator whose plane crashed, killing all five on board, saying he appeared indifferent to the tragedy and had little empathy for the victims and their families.
State Coroner Terry Ryan also recommended the peak aviation authority investigate the conduct of an aircraft maintenance engineer who falsely claimed to have installed a potentially lifesaving seat stop in the doomed aircraft's maintenance records.
Mr Ryan today handed down his findings into the tragic skydiving crash at Caboolture in March 2014 which claimed the lives of pilot Andrew Aitken, skydive instructors Glenn Norman and Juraj Glesk and engaged Beenleigh couple Joseph King and Rahuia Hohua.
Mr Ryan's recommendations can be found at the bottom of the story.
On March 22, 2014, the Adrenaline Skydivers Cessna, VH-FRT, climbed to about 200 feet with the pilot and four passengers when it suddenly plummeted to the ground and burst into flames, killing all on board.
During the inquest, the counsel assisting the coroner submitted it was probable that the pilot's seat slid backwards which caused the pilot to lose control.
But Mr Ryan said despite evidence that suggested the pilot had flown the plane with its seat off the rails the previous weekend, he couldn't conclude that a seat slide had been the cause of the crash because the plane had also been flown twice on the morning of the crash without incident.
"I am unable to find precisely what caused Mr Aitken to be unable to operate the flight controls of FRT resulting in an aerodynamic stall and the aircraft falling to the ground," he said.
The doomed plane belonged to Paul Turner, the sole owner and operator of the business Adrenalin Skydivers Pty Ltd which traded as Skydive Bribie Island, and who Mr Ryan slammed as an "unimpressive witness".
"He adopted a defensive and combative demeanour at the inquest and was evasive and non-responsive in answers to questions," the coroner said.
"For reasons unknown, he appeared to have taken little interest in the investigation into the causes of the crash of FRT which resulted in the deaths of his colleagues and clients.
"His indifference was demonstrated by his acknowledgment that he had not read much of the ATSB report which he described as 'rubbish'.
"He appeared to have little empathy for the families and friends of those lost in this crash which could have also taken his own life."
He also recommended the Civil Aviation Safety Authority investigate the conduct of aircraft maintenance business Ian Aviation run by Ian Colville.
During the inquest, the court heard the plane had been maintained by Ian Aviation and that Mr Colville had falsely claimed to have installed in the plane's logbook that he installed a secondary seat stop inertia reel in the plane which he then charged Cessna $856USD for.
"Mr Colville accepted that the logbook entry recording the installation of the secondary seat stop in FRT on 30 October 2011 was false," Mr Ryan found.
"He also accepted that in making a claim through Airflite as part of the Cessna extended warranty scheme, he made a false representation to Airflite for the purposes of obtaining the reimbursement from Cessna."
During the inquest, Mr Colville claimed Mr Turner had declined the installation of the seat stop because it would add too much weight to the plane.
But the coroner said that claim lacked plausibility and said in 2013, months before the crash, Mr Turner had asked Mr Colville to install the device but the part did not arrive at the maintenance shop until after the crash.
"The implication of the evidence given by Mr Colville is that if the secondary seat stop that was ordered and obtained for FRT in 2011 had been installed in that aircraft at that time, the inertia reel system is likely to have been effective to prevent an uncommanded rear slide of the pilot seat on 22 March 2014, assuming it had been properly connected to the seat," Mr Ryan wrote.
The coroner made a number of recommendations including that the Australian Parachute Federation revise its policies to assess whether Chief Instructor candidates are "fit and proper persons" and of "good repute".
He also recommended a thorough review of the training jump pilots receive, the regularity of proficiency checks and the possibility of a new pilot rating or endorsement in relation to jump pilots.
Section 46 of the Coroners Act 2003 provides that a coroner may comment on anything connected with a death that relates to public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future. I make the following recommendations:
I recommend that the APF revise its policies and procedures for the assessment of whether candidates for and holders of the position of Chief Instructor and others in control of parachuting organisations are 'fit and proper persons' and of 'good repute'.
I recommend that the APF require club members using Cessna 206 type aircraft or any similar aircraft with pilot seats that slide on rails to only use such aircraft as jump aircraft for tandem parachute activities where the aircraft has a secondary seat stop mechanism installed.
I recommend a thorough review of the requirements of the CASA approved APF Jump Pilot Manual, and its suitability for providing appropriate risk-based standards for all air operations conducted by APF club members.
I recommend that CASA and the APF review the implications for public safety of low-time or part-time jump pilots flying sorties in aircraft owned by APF club members and organisations not controlled by persons with the background and experience of an AOC operator.
Issues that should receive particular attention include:
(a) the level of training that jump pilots should be receiving and the introduction of specified and appropriately rigorous standards that would apply to jump pilots conducting flights transporting tandem parachutists to the point of departure from the aircraft;
(b) The need for more regular proficiency checks of jump pilots with a qualified examiner, in accordance with a checking syllabus approved by CASA where the syllabus would focus on matters germane to the airlift component of flights carrying tandem parachutists;
(c) The creation of a new operational rating or endorsement with special attention to moulding or expanding the application of the general competency rule contained in regulation 61.385 of the CASR to jump pilots to ensure a far higher standard of airmanship by jump pilots than is presently required; and
(d) Surveillance of the 'airlift component' of parachuting operations by CASA flying operations inspectors on a regular or systematic basis accompanied, where resources permit, by area safety officers of the APF.