Cessna 185E Floatplane, VH-HTS Calabash Bay, NSW - ATSB

CASA Civil Aviation Safety Authority C185 Cessna A185E DAM District Airworthiness Manager (CASA) DFOM District Flying Operations Manager (CASA) EST Eastern Standard Time FOB Flying Order Book (South Pacific Seaplanes) FOI Flying Operations Inspector hPa Hectopascals MAOC Manual of Air Operator Certification MD Managing Director MHz Megahertz NCN Non-compliance notice Octa Cloud amount expressed in eighths QNH An altimeter sub-scale setting to show height above sea level SPS Aquatic Air Pty Ltd, trading as South Pacific Seaplanes Note 1. All bearings are in degrees magnetic unless otherwise indicated. Note 2. All times are Australian Eastern Standard time (Co-ordinated Universal Time + 10 hours) unless otherwise stated. Note 3. For the purposes of this report Pilot Operating Handbook and Owners Manual are regarded as having the same meaning. Note 4. Scattered cloud is equivalent to 3–4 octas. Broken cloud is equivalent to 5–7 octas. Note 5. ‘The accident’ refers to the accident near Berowra on 26 July 1998 unless otherwise indicated. Note 6. ‘The pilot’ refers to the pilot in command of the accident aircraft, unless otherwise indicated. Note 7. A reference to Berowra means the Berowra alighting area located near Cunio Point, as distinct from Berowra Waters. v INTRODUCTION The main purpose of investigating air safety occurrences is to prevent aircraft accidents by establishing what happened, how and why the occurrence took place, and determining what the occurrence revealed about the safety health of the aviation system. Such information can be used to make recommendations aimed at reducing or eliminating the probability of similar occurrences, and where appropriate, to increase the safety of the overall system. To produce effective recommendations, the information collected during the course of the investigation, and the conclusions reached, must be analysed in a way that reveals the relationship between the individuals involved in the occurrence, and the design and characteristics of the system within which those individuals functioned. This investigation was conducted in accordance with the International Civil Aviation Organisation (ICAO) international standards and recommended practices for aircraft accident investigation, as described in Annex 13 to the Convention on International Civil Aviation (Chicago 1944). Particular regard was also given to the general principles of the analytical model outlined in ICAO circular 247-AN/148 (Human Factors Digest No. 10). It was not the purpose of this investigation to determine blame or apportion liability. Experience has shown that occurrences are rarely the result of a simple error or violation but are more likely to have been due to a combination of a number of factors, any one of which by itself was insufficient to cause a safety breakdown. Common elements in any occurrence are likely to be: • Unsafe acts such as errors or violations having an immediate adverse effect (generally associated with operational personnel). • Local factors, related to the tasks being performed, that are likely to encourage unsafe acts. These factors can include such things as inadequate or unsafe procedures, time pressures, work culture, equipment deficiencies and environmental conditions. • Organisational deficiencies associated with poor management policies and practices within organisations. Often these failures can remain dormant and unrecognised for long period. • Safety defences that should have been capable of providing barriers and safeguards to detect, warn and protect the system from human and technical failures arising from the three previous elements. An insight into the safety health of an organisation can be gained by an examination of its safety history, and of the environment within which it operates. A series of apparently unrelated safety events may be regarded as indicators of an underlying systemic failure. vi 1 On Sunday, 26 July 1998, at about 1324 EST, a Cessna A185E floatplane, VH-HTS, crashed onto a ridge forming the southern shore of Calabash Bay NSW. The accident occurred during a go-around manoeuvre following an unsuccessful landing approach to the Berowra water alighting area. At the time of the accident the Calabash Bay area was affected by strong winds, widespread rain and showers, low cloud, and reduced visibility. The aircraft was operated by South Pacific Seaplanes and was undertaking a charter flight from Palm Beach to Berowra. All five occupants, including the pilot, suffered fatal injuries. The aircraft was destroyed by impact forces. The investigation found that the circumstances of the accident were consistent with uncontrolled flight into terrain. The decision by the pilot to carry out a go-around into a confined area surrounded by steep-sided terrain was the culminating factor in a combination of local factors, organisational deficiencies and inadequate safety defences. Local factors included poor weather conditions, a lack of formal procedures to provide safe methods of operation, and commercial pressures. Organisational deficiencies were identified within South Pacific Seaplanes concerning the management and conduct of charter operations carried out by that company, and in the safety regulation of those operations by the Civil Aviation Safety Authority. During the investigation a number of safety deficiencies were identified. Safety actions to address those deficiencies are currently being formulated by the Bureau of Air Safety Investigation. A description of those deficiencies, and corresponding safety actions, will be summarised in section 4 of the final report. SYNOPSIS 2 Berowra Creek Berowra Waters Calabash Bay Accident site Deep Bay 3 1. FACTUAL INFORMATION 1.1 History of the flight A Cessna A185E floatplane, VH-HTS, departed Palm Beach at 1309 on a visual flight rules charter flight to take four passengers to a waterside restaurant at Berowra Waters. The area was under the influence of a moist north-easterly airflow, producing widespread rain and showers, reduced visibility, and a cloud base of about 800 ft. Various witnesses subsequently saw the aircraft flying low along the Hawkesbury River before commencing what appeared to be a downwind landing approach, in a south-westerly direction, along Berowra Creek. The aircraft descended to within about 30 ft of the water before climbing ahead towards the confines of Calabash Bay. Witnesses described the aircraft climbing over the middle of the bay to a height level with an adjacent ridgeline, about 300 ft above the water. The aircraft then initially banked to the right before entering a turn to the left at a bank angle of about 45˚. A witness reported that the aircraft appeared to encounter turbulence during the turn. The wings were seen to rock before the aircraft disappeared from sight. Other witnesses in the area heard the aircraft engine, apparently operating normally, followed by the sound of a ground impact. Calabash Bay as viewed by witnesses observing the aircraft from Deep Bay 4 The aircraft crashed at about 1324 into heavily timbered sloping terrain, on the ridge forming the southern shore of Calabash Bay. All five occupants suffered fatal injuries. 1.2 Injuries to persons Crew Passengers Other Total Fatal 1 4 — 5 1.3 Damage to aircraft The aircraft was destroyed by ground impact forces. 1.4 Other damage No other property damage was reported. The accident site as viewed from Calabash Bay Accident site 5 1.5 Pilot in command Licence category: Commercial Medical certificate: Class 1 Total hours: 1,269 Total on floatplanes: 562 Total on type: 53.7 Total last 90 days: 75.1 Total on type last 90 days: 38.8 Total last 30 days: 30.3 Total on type last 30 days: 17.2 Total last 24 hours: 2.6 Last check: 5 July 1998 Last check on type: 9 April 1998 1.5.1 Pilot training and operational experience The pilot had obtained a private pilot licence in 1979 and a commercial licence in 1981. He gained a single-engine instrument rating in 1983, which he maintained for most of the time until 1993. Up to that time he had accrued 704 flying hours, including 526 hours as pilot in command. He did not fly again until 28 June 1997, then completed a biennial flight review on 6 July 1997. During July 1997 the pilot completed a ‘float alighting gear’ endorsement on the Maule M7 aircraft. This training totalled 7.9 hours and was conducted by two approved South Pacific Seaplanes company pilots. The pilot continued to fly the Maule M7 as pilot in command under supervision until the end of August. That was in order to meet a company requirement of 50 hours in-command-under-supervision experience before being able to commence charter operations. Some of that experience was gained on positioning flights, with the remainder being paid for by the pilot. Although the pilot subsequently met the 50-hour requirement, the chief pilot at the time had some doubts as to his suitability to conduct commercial floatplane operations. It was decided that the pilot should undertake further in-command-under-supervision flying, resulting in an additional 16.3 hours, including 1.2 hours as pilot in command. On 12 September 1997, the chief pilot made the following entry in the pilot’s check and training file: ‘50 hours completed and flies to safe standard. May fly to Cronulla, Palm Beach, and Rose Bay in winds not in excess of 10 kts; Cottage Point, Peats Bight, Pasadena, Akuna Bay in winds not in excess of 10 kts with another company aircraft’. On 17 September, the senior pilot made a further entry: ‘Has been rostered on to fly as company line pilot. May fly into Cronulla, Rose Bay, Palm Beach, Cottage Point, Pasadena, and Peats Bight in winds not exceeding 15 kts’. The pilot commenced charter operations in Maule M7 aircraft on 18 September. On 5 February 1998, the chief pilot converted the pilot onto the Cessna 185 aircraft. That training comprised 0.4 hours of basic handling, low-level flying, landings and moderate turns. On 9 April, the pilot underwent a company check flight of 0.9 hours, after which he flew the Cessna 185 regularly on charter flights. A 6-monthly check on the Maule M7 was carried out on 11 April, followed by a line check on 5 July. No problems were noted. Both check flights were conducted as pilot in command under supervision, while positioning to pick up fare- paying passengers. 6 According to his logbook, the pilot flew into Berowra once during his in-command-under- supervision training. The supervisory pilot on that flight reported that he would not have been conducting any check or training. He could not recall the approach method used, but stated that the approach must have been straightforward, otherwise he would have conducted it himself. The pilot flew into Berowra at least twice as a passenger during his in-command- under-supervision training. The pilots in command of those flights could not recall what approach methods were used. The pilot first flew solo into Berowra on 5 October 1997. At that time South Pacific Seaplanes did not have a chief pilot. Between 5 October and 11 October charter operations were conducted under an Air Operators Certificate issued to Air Pioneer, a Townsville-based operator. The process used to assess the pilot’s proficiency to fly into Berowra could not be determined, and there were no entries in the pilot’s check-and-training file authorising operations at Berowra. Logbook entries indicated that the pilot had flown into Berowra on 47 occasions prior to the accident flight. Other company pilots, including the chief pilot, were unaware of the approach methods used by the pilot at Berowra. His last eight flights into Berowra were his only flights there in the Cessna 185. Four of those flights carried passengers. On each of these occasions he approached from the north-east and landed to the south-west. 1.5.2 Pilot performance Company pilots who flew with the pilot reported that he had good aircraft handling skills and appeared to be competent. No one reported noticing anything unusual in his flying behaviour. Most pilots reported that they had not flown with him enough to comment on his aviation decision-making ability. It was also reported that the pilot had experienced some difficulties in adapting to floatplane operations, particularly when assessing the effects of weather on water surface conditions, and when using appropriate water handling techniques. On 27 November 1997, the pilot was involved in a landing accident at Rose Bay, involving a Maule M7. The aircraft was on a positioning flight from Palm Beach to Cronulla. Arriving in the Cronulla area, the pilot found the weather conditions were too severe to permit a landing approach and diverted to Rose Bay until conditions improved. At Rose Bay the pilot commenced an approach to land in a north-easterly direction, directly into wind. Just before touchdown, the aircraft yawed sharply to the right. The left wingtip struck the water and the aircraft cartwheeled, coming to rest inverted. The pilot escaped with minor injuries. A significant factor in that accident was that there had been a sudden wind-shift during the final stages of the landing approach, with little or no warning to the pilot. The wind-shift was possibly associated with thunderstorm activity in the Sydney area. On 12 December 1997, the pilot was involved in a taxiing incident at Rose Bay when his aircraft, a Maule M7, collided at low speed with a catamaran. The collision reportedly resulted in minor damage to the left wing of the Maule, and some minor scratching to a guardrail on the catamaran. The pilot had seen the catamaran on his left side and believed it would give way. The captain of the catamaran did not see the floatplane until just before the collision. On 15 January 1998, the pilot was also involved in a taxiing incident at Cronulla. While re- positioning a Maule M7, he failed to stop the aircraft in time. The resulting collision with a dock caused minor damage to one of the floats. 1.5.3 Other pilot information The pilot was employed by South Pacific Seaplanes on a casual basis, generally flying 2 or 3 days a week, and paid an hourly rate for hours flown. He also worked as a salesman 3 to 4 days a week. During the 3 days prior to the accident the pilot was reported to have slept and eaten normally. His only flying during that period had been 1.9 hours on 24 July. On the day before the accident he relaxed and did various odd jobs. After waking at 0600 the next morning, he had breakfast, then reported for work at about 0730. On the day of the accident the pilot’s first flight commenced at about 0830. He carried out three positioning and three passenger flights before the accident flight. Passengers, and other people who talked to the pilot during the day, reported nothing unusual in his behaviour. No evidence was found to indicate the pilot was experiencing any personal or medical problems that may have adversely affected his performance. 1.6 Aircraft information 1.6.1 Aircraft data Manufacturer: Cessna Aircraft Corporation Model: Cessna A185E Serial Number: 185-01835 Registration: VH-HTS Country of manufacture: USA Date of manufacture: 1971 Imported from Canada: 1986 Float Alighting Gear: Pee Kay Model C 3500 Certificate of Registration Holder: Outback Air Pty Ltd, trading as Wilderness Air No: MBN 00489/01 Issued: 26 August 1986 Note: At the time of the accident the Certificate of Registration had not been transferred, although the aircraft had been sold to South Pacific Seaplanes. Certificate of Airworthiness: No: MB 489 Issued: 14 August 1987 Maintenance release: No: 265168 Issued: 23 May 1998 Valid to: 23 May 1999 or 7,492.13 hours (whichever occurred first) Total airframe hours: 7,486.5 Allowable take-off weight: 1,519 kg (floatplane variant) Estimated take-off weight: 1,424 kg Estimated weight at occurrence: 1,411 kg Allowable centre of gravity limits: 1,028 mm to 1,181 mm aft of datum Centre of gravity at occurrence: 1,163 mm aft of datum 7 1.6.2 Engine and propeller Engine manufacturer: Teledyne Continental Model: IO-520F Propeller manufacturer: McCauley Model: D3A32C 90/82NC-2 (3-blade, constant speed) 1.6.3 Weight and balance Prior to the flight, the pilot had partially completed a company loading form, which showed the centre of gravity to be within permissible limits. However, although the aircraft basic weight and passenger weights had been recorded, the take-off weight had not been calculated. Subsequent estimates showed that the aircraft met weight and balance limitations for the accident flight, even though the actual fuel quantity could not be positively established. The pilot’s entry in the aircraft flight record indicated a fuel quantity of 144 L on departure from Palm Beach. An inspection of previous fuel records revealed inaccuracies when recording quantities. Although dipsticks were available to assist pilots to determine fuel tank contents, the investigation was unable to determine if the pilot had dipped the tanks prior to the flight. 1.6.4 Serviceability The aircraft had been maintained in accordance with Civil Aviation Regulations Schedule 5, and approved variations to that schedule. A review of the aircraft maintenance data indicated that there was no maintenance outstanding at the time of the accident. The maintenance release was valid and contained an endorsement indicating that the ‘suction’ pump was unserviceable. The effect of this was to render the gyroscopic attitude indicator inoperative, which was labelled as unserviceable. The horizontal situation indicator was also labelled as unserviceable. Neither instrument was required for a charter flight conducted in accordance with the visual flight rules. 1.6.5 Climb performance Civil Aviation Order section 20.7.4 specified the minimum aircraft climb gradients for takeoff, climb and landing climb (go-around). In order for the Cessna 185 floatplane to comply with climb gradient requirements the aircraft flight manual supplement for the Pee Kay C 3500 Floats limited the maximum allowable weight for take-off and landing to 1,519 kg. The manufacturer’s Pilot Operating Handbook for the floatplane variant stated: ‘If an obstruction ahead requires a steep climb angle, a best angle-of-climb speed should be used with flaps up and maximum continuous power. This speed is 68 kt at sea level’. The speed quoted in the company’s copy of the Owners Manual (landplane) for this aircraft was 75 kts. Climb performance for the Cessna 185E floatplane variant was published in the Pilot Operating Handbook. The only data given in tabular format was for maximum rates of climb. The calculated maximum rate of climb for the ambient conditions was 985 ft/min, 115 ft/min less than the equivalent climb performance of the landplane version. South Pacific Seaplanes did not possess a copy of the Cessna 185E Pilot Operating Handbook (floatplane). The only climb performance information available to South Pacific Seaplanes’ flight crew was from a copy of the Cessna 185F Owners Manual (landplane) held by the operator. 8 1.6.6 Turning performance The minimum turning radius of the aircraft in still air with flaps up, at an angle of bank of 45˚, and an airspeed of 75 kts, was calculated to be 153 m. The pilot had an area about 500 m wide in which to manoeuvre within Calabash Bay. 1.7 Meteorological information 1.7.1 Weather forecasts The company practice was to obtain briefing information by facsimile from Airservices Australia each morning. That information included weather forecasts for meteorological areas 20 and 21, as well as terminal forecasts for Bankstown, Sydney, Williamtown and Wollongong. The accident flight was conducted within area 20. Airservices Australia records confirmed that briefing information was transmitted to the operator at 0744 on 26 July 1998. A copy of that material was subsequently located in the company office at Cronulla. The synoptic situation was reflected in the area 20 forecast, which indicated that the area was affected by a moist north-easterly airflow, producing widespread rain and showers over the greater Sydney and central coastal regions, with associated areas of low cloud and reduced visibility. An amended area 20 forecast was issued for the period 0300-1500, indicating the wind at 2,000 ft was 050˚ at 25 kts, with scattered stratus at 300 ft and scattered cumulus and strato- cumulus at 2,000 ft, to sea and about the coast. There were forecast areas of broken stratus at 2,500 ft east of the ranges, and areas of broken alto-cumulus and alto-stratus above 7,000 ft. Visibility was expected to be reduced to 3,000 m in drizzle and rain, and 4,000 m in showers. 1.7.2 Specialist weather analysis An analysis by the Bureau of Meteorology estimated the actual weather conditions in the Calabash Bay area at 1325, were: a wind at 1,000 ft of 030˚ at 25 kts, scattered stratus at 300 ft, broken to overcast stratus at 800 ft, and cumulus and layered cloud above the low stratus. Visibility was 6,000 m reduced to 3,000 m in intermittent rain and showers. Temperature was 13ºC, dewpoint 12.5ºC, with a relative humidity of 97%. QNH was 1,016 hPa. 1.7.3 Observed weather conditions Accounts of the weather at Calabash Bay, by two helicopter pilots at the scene within 30 minutes of the accident, were generally consistent with the assessment provided by the Bureau of Meteorology. There were some heavy showers in the area, and continuous light drizzle. Visibility was described as good in some areas, but less than 2,000 m in heavy showers. There were patches of low cloud and scud on some of the hilltops. Ground witnesses reported that the hilltops in the Calabash Bay area were clear of cloud at the time of the accident. Surface wind in the vicinity of the Berowra alighting area was estimated by observers as 050˚ at 15 kts, gusting to 25 kts. The wind below the hilltops was gusting, and windshear was considered to have been significant. Turbulence was assessed as moderate to severe. It was also considered likely that mechanical turbulence would have been present in the Calabash Point area, due to the steep sloping terrain to windward. 9 1.7.4 Visual flight rules The pilot was required to comply with the visual flight rules for the intended flight. Civil Aviation Regulation 172 (1) requires the pilot of an aircraft flying at a height of less than 2,000 ft to be able to navigate by reference to the ground or water. When flying at a height below 3,000 ft, or within 1,000 ft of terrain, the provisions of Aeronautical Information Publication (RAC-8) require the pilot to be able to remain clear of cloud, with a minimum flight visibility of 5 km. Civil Aviation Regulation 174 (1) also states that flight visibility shall be determined by the pilot in command from the cockpit of the aircraft while in flight. 1.8 Aids to navigation Not considered relevant to the investigation. 1.9 Communications The aircraft was fitted with two VHF communications systems appropriate for the flight being undertaken. The flight from Palm Beach to Berowra was conducted entirely in ‘G’ airspace, requiring no mandatory broadcasts. However, floatplane operators had agreed, in the interests of safety, to broadcast an inbound call on the area frequency of 125.8 MHz, approaching the alighting area. Another company pilot airborne at the time, heard the pilot report inbound to Berowra. He was unable to determine from that transmission what type of approach the pilot intended making, or the landing direction to be used. An automatic voice recording of the area frequency did not capture that transmission. However, terrain shielding of radio transmissions is reported to be a common occurrence for aircraft operating at low level in that area. 1.10 Aerodrome information 1.10.1 General description The Berowra water alighting area was located at Cunio Point Reach on Berowra Creek, where the waterway was approximately 200 m wide and 2,000 m long. It was aligned north- east/south-west and bordered by tree covered terrain rising steeply to elevations of between 400 ft and 600 ft. At the north-eastern end the creek changed direction to the north, at Collingridge Point. At the south-western end of Cunio Point Reach is Calabash Point, where the creek forks. The southern arm of the fork turns 90˚ to the south-east and gradually narrows to become Berowra Waters. The western arm becomes the entrance to Calabash Bay. A powerline spanned the entrance to the bay at a minimum elevation of about 80 ft. The water alighting area at Berowra is not controlled by air traffic services. The pilot of an aircraft using the alighting area is required to make an assessment about the suitability of the area before landing or taking off. Civil Aviation Regulation 92 (1) states (in part) that: ‘An aircraft shall not land at, or take-off from, any place unless: (d) the place (not being a place referred to in paragraph (a), (b) or (c)) is suitable for use as an aerodrome for the purposes of the landing and taking-off of aircraft; and, having regard to all the circumstances of the proposed landing or take-off (including the prevailing weather conditions), the aircraft can land at, or take-off from, the place in safety’. 10 Civil Aviation Regulation 92 (1) did not specify the method of determining what ‘circum- stances’, other than the prevailing weather conditions, should be considered in any particular case. Those matters are the responsibility of the pilot in command and, in some circumstances, are shared with the aircraft operator. 11 Accident site Witness Berowra Creek Water Alighting Area 1.10.2 Advisory information Civil Aviation Advisory Publication (CAAP) 92-1(1) provided guidelines for aircraft landing areas, including water alighting areas used by aircraft engaged in charter operations. Those guidelines recommended the minimum physical characteristics of a water alighting area, and factors that should be considered prior to using an area. The introduction to the CAAP contained the following passages: ‘The information contained in this publication is advisory only. There is no legal requirement to observe the details set out in this publication’. ‘These guidelines set out factors that may be used to determine the suitability of a place for the landing and taking-off of aeroplanes. Experience has shown that, in most cases, application of these guidelines will enable a take-off or landing to be completed safely, provided that the pilot in command: (a) has sound piloting skills; and (b) displays sound airmanship’. The water alighting area at Berowra met the minimum physical dimensions published in CAAP 92-1(1). Although those dimensions provided for obstacle-free gradients for approach, takeoff and initial climb, the obstacle-free areas only extended 900 m beyond the anticipated point of touchdown or liftoff. There was no provision in the CAAP to provide for terrain clearance beyond the obstacle free areas, or a circling area as required for a licensed aerodrome. Terrain surrounding the alighting area precluded circling safely below about 1,000 ft. Therefore, an aircraft taking off or going-around from a baulked landing approach, in either direction, would have had to climb to that altitude by following the watercourse. 1.11 Flight recorders The aircraft was not equipped with a flight data recorder or cockpit voice recorder, nor were they required by regulation 1.12 Wreckage and impact information 1.12.1 Accident site description The aircraft had impacted nose-down in a near vertical attitude, into steeply sloping, heavily timbered terrain, at an elevation of about 120 ft. Both floats had collided with a large boulder and been driven rearwards, with the right float striking the right horizontal stabiliser. Both outboard wing sections were severely disrupted as the aircraft descended through trees. The right outboard wing restrained the aircraft in its final resting position. 12 13 14 15 1.12.2 Technical examination of the wreckage After a preliminary on-site examination, the wreckage was moved to a holding facility for further investigation. 1.12.2.1 Structure The aircraft damage was consistent with a relatively low-speed, near-vertical impact with the ground. The engine and firewall had been driven rearwards, and the wings and supporting structure had moved forward and down until almost contacting the glareshield. The propeller was torn off in the impact. All extremities of the aircraft were found at the accident site, consistent with the aircraft being intact at the point of initial contact with trees. A considerable quantity of fuel remained in the ruptured fuel tanks, which continued to leak for about 24 hours after the accident. Both floats were torn and buckled rearwards to their respective steps, and the supporting struts were buckled and bent. 1.12.2.2 Flight controls No evidence was found of any pre-existing defect or malfunction of any part of the flight control system. Single flight controls were fitted to the left control position. The left horn of the control wheel had separated. The elevator trim was found jammed about halfway towards the full nose-down position. That jamming was due to fuselage crushing at the underfloor sprocket bracket, aft of the trim wheel. When the crushed area was straightened the system functioned normally. The wing flaps were fully retracted. The engine and propeller controls had been severely disrupted and their respective settings could not be determined. The ignition key was broken off and the ignition switch was positioned at BOTH. The master switch was on. The air-activated stall warning horn functioned normally when tested. 1.12.2.3 Engine and propeller The engine was dismantled for further examination. No evidence was found of any pre- existing defect or malfunction of the internal components. Both magnetos had separated from the accessory case during the impact sequence. The magnetos, complete with ignition system wiring and sparkplugs, functioned normally when tested. A maintenance release endorsement, dated 21 June 1998, stated that the ‘suction’ pump was unserviceable. When the pump was removed from the case, the drive coupling was found to have been sheared. On dismantling the pump, the internal carbon vanes were found shattered and jammed. The propeller internal blade-lock mechanism was damaged and the blades could be rotated in the hub. Leading edge damage and bending of the propeller blades was consistent with the propeller rotating under power at impact. 1.12.2.4 Fuel system The fuel selector was selected to the left fuel tank. The engine fuel strainer was full of clear uncontaminated fuel, and the strainer was clear. There was a small amount of sediment in the strainer bowl. Clean fuel was found in the engine fuel distributor manifold. All recovered fuel samples were tested with water sensitive paste. No evidence of water was detected in any of the samples. All samples examined were consistent with aviation gasoline grade 100/130, the approved grade for the aircraft type. 1.12.2.5 Cockpit instruments The cockpit instruments were severely damaged as a result of the impact, and no worthwhile calibration testing could be undertaken. 1.13 Medical and pathological information There was no evidence found to indicate that the pilot suffered from any pre-existing condition that may have affected his capacity to function normally. 1.14 Fire There was no evidence of any pre-impact or post-impact fire. 1.15 Survival 1.15.1 Crew and passenger restraint The aircraft cabin contained six seating positions, in two rows of dual seats and a rear two- place bench seat. The pilot and front seat passenger seats were fitted with both lap and shoulder restraints. The remaining four passenger seats were fitted with lap belts only. Four of the five occupants died immediately on impact. A passenger occupying the left rear bench seat died at the scene shortly after. The right rear bench seat was unoccupied. During the impact sequence, the pilot and front seat passenger lap belts remained fastened. However, neither was wearing their respective shoulder restraint. The second row, left seat outboard seat-belt stitching had failed at the belt tang. The tang was locked in the buckle and the right belt was intact. The right seat belt was unlocked and the right outboard belt anchor point had been torn from the aircraft structure as a result of overload failure. The second row inboard seat belts were attached to the floor structure using a single attachment point instead of individual attachments. Moreover, that improper attachment did not use either of the two attachment points fitted to the aircraft structure by the manufacturer. The left seat belt of the rear bench seat was fastened; however, the inboard belt anchor bolt had failed in overload. The investigation found that the anchor bolt was not the correct part. Metallurgical examination found that although the bolt was of lower strength than the correct part, its strength was sufficient to meet the aircraft design specifications. A specialist post-mortem examination of the pattern of injuries sustained by the occupants suggested that the failure of the lap restraints in the middle and rear seat rows would have allowed the occupants of those seats to be projected forward, onto the seats in front. This cascade effect could have been initiated by the failure of the rear seat-belt mounting, consequently contributing to the progressive loadings on the seats and occupants in front. The type and severity of injuries sustained suggested that, had adequate lap and upper body restraint been fitted and worn, those features would have aided survivability. There was no regulatory requirement for the fitment of upper body restraints to other than the front row of seats. 1.15.2 Emergency locator transmitter An emergency locator transmitter (ELT) mounting bracket and fixed antenna were installed in the rear of the aircraft behind the cabin area. However, there was no ELT fitted, nor was the aircraft required to carry one for the intended flight. 1.16 Tests and research Not relevant to the investigation. 16 17 1.17 South Pacific Seaplanes organisation and management 1.17.1 Air Operator Certificate holder responsibilities In accordance with the provisions of section 28BE of the Civil Aviation Act 1988: ‘(1) The holder of an AOC must at all times take all reasonable steps to ensure that every activity covered by the AOC, and everything done in connection with such activity, is done with a reasonable degree of care and diligence. ‘(2) If the holder is a body having legal personality, each of its directors must also take the steps specified in subsection (1). ‘(3) It is evidence of a failure by a body and its directors to comply with this section if an act covered by this section is done without a reasonable degree of care and diligence mainly because of: (a) inadequate corporate management, control or supervision of the conduct of any of the body’s directors, servants or agents; or (b) failure to provide adequate systems for communicating relevant information to relevant people in the body’. Section 28BD of the Act states that: ‘The holder of an AOC must comply with all requirements of this Act, the regulations and the Civil Aviation Orders that apply to the holder’. 1.17.2 Company overview The main purpose of the company was to conduct charter flights utilising small floatplanes, to cater for small groups of people wanting to sightsee, travel to restaurants located on waterways in the Sydney area, or pursue other similar activities. The Maule M7 aircraft was initially selected because of its performance, its ability to operate in confined areas, and its relatively low operating costs. The company catered for a niche market, and had proven popular with people requiring that type of service. Later, following an accident involving a Maule, a Cessna 185E was added to the aircraft types operated by the company. Since the company had commenced operations in the middle of 1994 it had been beset by a number of safety related occurrences, as well as a series of complaints from a rival organisa- tion, and from disaffected former South Pacific Seaplanes employees. A summary of these events, and the responses to them, is described in subsection 1.22. 1.17.3 Organisational structure Aquatic Air Pty Ltd was a proprietary company trading as South Pacific Seaplanes, ACN 066328292, with a paid up share value of $2.00. The company was registered on 5 September 1994. Its directors were a married couple who, although having considerable experience in other commercial ventures, had no previous commercial aviation experience. One was appointed as Managing Director and Air Operators Certificate holder, while the other was appointed secretary. The Managing Director said that he had owned an aircraft for the previous 7–8 years, and that he held a private pilot licence. A chief pilot supervised the company flight operations. Apart from the chief pilot, two pilots were employed on a full time basis. The pilot involved in the accident was employed on a casual basis. All four pilots commenced flying for South Pacific Seaplanes between July and September 1997. None had previous floatplane experience. The company also employed two office staff to assist with bookings and other administrative functions. The main operational base was located at Cronulla, with additional facilities at Rose Bay and Palm Beach. 18 1.17.4 Financial fitness There was no evidence found to indicate that financial problems may have had any significant adverse effect on the operation of the company. During a CASA safety audit in April 1998 the audit team requested a financial profile as part of a business report on the company, from a service provider. That report indicated the company financial risk ratings were at about the industry average. However, the South Pacific Seaplanes Managing Director declined to release additional information to the service provider unless he knew who was making the inquiry. 1.17.5 Relationship with CASA During the 4 years since South Pacific Seaplanes had commenced operating, the conduct of flying operations carried out by that company had been characterised by a series of safety related events, as described in subsection 1.22. Those events triggered various responses from CASA, including formal counselling of a chief pilot, a safety audit, two proposals to suspend chief pilot approvals, two proposals to suspend or cancel the South Pacific Seaplanes Air Operators Certificate, and a Notice of Suspension of the South Pacific Seaplanes Air Operators Certificate. The Air Operators Certificate was subsequently suspended, pending cancellation, following the accident on 26 July 1998. When South Pacific Seaplanes first applied for an Air Operators Certificate the company had provided a commercially produced operations manual adapted for their operation. Although that manual was amended to reflect company seaplane operations, perceived deficiencies in the operations manual by CASA became a continuing problem for South Pacific Seaplanes. The Managing Director said that in hindsight, the original manual was not suitable for seaplane operations and if he had to do it again (produce an operations manual) he would write his own. Since the commencement of South Pacific Seaplanes operations, the Managing Director had gained the impression that the assigned flying operations inspector had been biased towards a rival organisation, and had been obstructionist. He had raised this issue with both the former and current regional managers. But, because the district office did not have another float- qualified flying operations inspector, he was told the assigned flying operations inspector would continue to oversee both organisations. The Managing Director said that he saw the role of the assigned flying operations inspector as being the link between the industry and the regulator. However, throughout the history of the company the relationship with the regulator had deteriorated to the extent that they were not on speaking terms. The Managing Director thought that if they had been on speaking terms then things would have been different. He had been told by the assigned flying operations inspector that CASA was not a teacher, and that they looked for compliant operators. The Managing Director explained that when the company had commenced operations everyone had been on a steep learning curve. He believed that if CASA had visited the company every 3–6 months, in those early days, then the end result would have been better for all concerned. The Managing Director felt that the current approach by CASA in not getting too close to operators was not a good way to foster relationships with the industry. He felt they (CASA) needed to get back into the old way of liaison with the industry, on an informal basis, to improve things. He also made the point that when applying for the initial issue of the Air Operators Certificate he had not been interviewed to assess his competency, nor had he been provided with any guidance material on what was expected of him in carrying out his responsibilities as an Air Operators Certificate holder. 19 The Managing Director indicated that another problem had been the high turnover of chief pilots. He felt that his first chief pilot had been very professional, however, there had been a falling out, resulting in his resignation. That person subsequently made a series of written complaints to CASA about South Pacific Seaplanes operations (see subsection 1.22). Considerable difficulties were experienced in obtaining pilots suitable for chief pilot approval. The Managing Director said he had problems with the next two chief pilots. Both left the company as a result of their deteriorating relationships with management. The next chief pilot agreed to act in that position for the time it took to arrange for someone else to take over, as he was taking up a position overseas. When he finally left, his replacement, who had no previous floatplane experience, had still not been approved by CASA. While that experience was being obtained, the Managing Director said that he was able to continue operations under the Air Operators Certificate of two other operators. Finally, on 16 October 1997 the current chief pilot was appointed. The Managing Director expressed a high regard for this person, and considered that if he had been the chief pilot from the outset, things would have been different. 1.18 South Pacific Seaplanes flight operations 1.18.1 Operations manual Civil Aviation Regulation 215 required an operator to provide an operations manual for the use and guidance of the operations personnel of the operator. When South Pacific Seaplanes initially applied for the issue of an Air Operators Certificate a ‘generic’ type operations manual, purchased from a commercial supplier, was submitted for approval. The assigned flying operations inspector subsequently recommended that the operations manual be revised, prior to the issue of the Air Operators Certificate, to cover aspects related to water operations, including authorised alighting areas. Deficiencies in the operations manual became a continuing problem for both South Pacific Seaplanes and CASA, resulting in a number of revisions. One ongoing concern related to the authorised landing area register not providing sufficient detail regarding alighting area dimensions, obstacles, and approach and climb gradients. At no time did the operations manual contain procedures and guidelines to inform flight crew how company aircraft should be operated at specific locations. In September 1997, CASA produced CAAP 215-1(0), Guide to the Preparation of Operations Manuals. The purpose of the CAAP was defined in the preamble to that document, and included the following statement: ‘This publication provides the operator with a standardised framework within which to present that information essential to the conduct of his operations. While compliance with this CAAP is not mandatory, standardisation provides benefits to the operator in terms of ease of compilation and speed of assessment by CASA, and provides a readily recognisable document for use by operations personnel’. The introduction to the CAAP included the following: ‘An operations manual (OM or alternatively ‘the manual’) is provided by an operator for the use and guidance of the operations personnel of the operator. It [the operations manual] shall contain such information, procedures and instructions with respect to the flight operations of all types of aircraft operated by the operator as are necessary to ensure the safe conduct of flight operations (CAR 215 (2)). ‘As part of its methodology for the safety regulation of industry, CASA will place increasing emphasis on operators to use safety systems in the oversight of their operations. An operations manual itself is a safety system and it will contain many sub-systems’. The CAAP also provided a sample manual. Within that manual various sections were described. Section A6.13 provided for ‘Operations at selected locations’. As a result of a safety audit conducted by CASA officers on 21–23 April 1998, a number of non-compliance notices were issued to South Pacific Seaplanes, two of which related to deficiencies in the company operations manual. At the time of that audit the South Pacific Seaplanes operations manual did not contain specific guidance for operations at selected locations. The non-compliance notices issued did not address that deficiency. Amendment 9 to the South Pacific Seaplanes operations manual was issued on 30 April 1998 in response to the non-compliance notices, and a copy provided to CASA on 8 May 1998. That amendment also made no reference to operations at specific locations, nor did it contain a section A6.13. In order to comply with condition 4 of a ‘stay’ order issued by the Administrative Appeals Tribunal on 21 May 1998 (see subsection 1.22, Summary of Significant Events), a new operations manual was produced, effective from 1 June 1998, and submitted to CASA on 5 June 1998. The format of the manual followed the guidelines of CAAP 215-1(0). Section A6.13 of the new operations manual (‘Operations at Specific Locations’) was listed as Reserved. As a result, at the time of the accident, there were no published procedures to provide guidance to South Pacific Seaplanes flight crew when operating into specific locations such as Berowra. 1.18.2 Flight crew perceptions During the course of the investigation, a number of pilots were interviewed who were either working for, or had worked for, South Pacific Seaplanes. Some commented that although the two directors of the company had limited experience with regard to floatplane operations, both had a continuing influence on operational decisions, often due to commercial imperatives. Almost all pilots indicated that the close scheduling of flights was a continuing problem. Some felt there was pressure exerted to overload aircraft, particularly when carrying four people in the Maule M7. Others commented that pressure was exerted to continue flying operations despite adverse weather conditions. The Managing Director encouraged a ‘give it a go’ attitude. A former company pilot made the observation that there appeared to have been three phases during the period that South Pacific Seaplanes had been operating. The first phase coincided with the term of the first chief pilot, who was well regarded, and ‘babied’ the company through the initial setting up period. The next phase was an interim period, during which a number of key personnel left the company, resulting in a loss of operational experience. The third phase commenced with the employment of the current chief pilot. A former chief pilot said that he had experienced hostility and ongoing pressures from the Managing Director and his wife when he tried to take action on safety matters, such as overloading. On one occasion he and two other pilots were told by the Managing Director that if they did not fly overloaded they would not have a business. He also stated that the company directors were largely unaware of operational issues, and thought that they had a lot of power but no operational responsibility. He also indicated that South Pacific Seaplanes was one of the busiest little charter firms in Australia, and could have benefited from better management. Two pilots employed by South Pacific Seaplanes at the time of the accident indicated that they had no problems with the company. Both got on well with the current chief pilot, and felt that pilots were able to have an input into company procedures. One indicated that the chief pilot appeared to be more safety conscious than most charter pilots, probably because of his instructional background. Company employees enjoyed a good rapport compared to earlier times when there had been trouble with staff. 20 21 1.18.3 Operations at Berowra The majority of pilots interviewed during the course of the investigation regarded Berowra as being a very difficult, if not the most difficult, alighting area used by South Pacific Seaplanes. Wind and weather appeared to be the main considerations when deciding on the suitability of Berowra. Wind funnelling was described as a real problem, particularly with wind speeds in excess of 10–12 kts. A former chief pilot said that approaches to Berowra had to be carefully planned, even in light winds, because the alighting area was almost a one-way strip. During the interviews it became apparent that there were no standard methods or procedures used by company pilots when operating at Berowra. This was evidenced by a number of past and present company pilots who described how they would make a landing approach to the north-east. They said they would approach the area from the north, descending in a reversal turn over Calabash Bay, before passing over the ruins of a building on Calabash Point as the aircraft was established on final approach. Others stated that they always made the approach by flying north over Berowra Waters before turning right to land in Berowra Creek. The current chief pilot reported that he had never flown over Calabash Bay when landing to the north-east, nor had he seen other floatplanes approach in that way. Pilots reported that they would generally try to take off to the north-east, even accepting a downwind component, rather than try to climb out to the south-west. Landings to the south- west were preferred in order to minimise taxiing times. The general consensus was that a downwind component of less than 10 kts could be accepted for a landing to the south-west, if other conditions were suitable. If a missed approach needed to be carried out in that direction, most pilots agreed that turning left and climbing along Berowra Creek was the only option. It also became evident that each pilot had different views about decision points, flying techniques, the conduct of missed approaches, and other operational procedures. Most pilots indicated that there was no stigma attached to making a missed approach. One very experienced pilot said he did not think he could have turned a Cessna 185 in Calabash Bay, whereas he could have done so with the Maule M7. Other pilots, including the current chief pilot, said they would not have attempted to fly into Calabash Bay on a missed approach. 1.18.4 Floatplane operations All of the pilots interviewed stated that floatplane operations were significantly different to landplane operations. They indicated that such things as decision points and approach procedures were difficult to define for their operations, due to the various factors that could affect the landing areas. In essence, they believed that their operations had to rely almost solely on pilot judgement rather than formally defined procedures or guidelines. This pilot ‘judgement’ appeared to refer to a series of general guidelines or decision rules for landing areas, that were meant to be explained to new pilots during their training and in-command- under-supervision phases. When the last four pilots commenced operations with the company, a lack of experienced floatplane pilots meant that this knowledge was not passed on as well as it might have been. 1.18.5 Cessna 185 conversion training and checking Training records showed that some conversion training on the Cessna 185 floatplane had been provided to company pilots. That conversion training consisted mainly of takeoffs and landings, and water handling. The Cessna 185 was not equipped with dual controls. Not one pilot interviewed recalled ever having attempted stall recovery, maximum rate turns, or go- around manoeuvres, either during conversion training or on subsequent proficiency checks. Only one pilot could recall practising steep turns. 22 Although the operations manual contained a checklist for sequences in a 6-monthly check, it did not include manoeuvres such as steep turns, or go-arounds. None of the company pilots converted to the Cessna 185 had exceeded 40 minutes of in-command-under-supervision training. Nor could any of the pilots interviewed recall carrying out a go-around in the Cessna 185. The cockpit checklist provided by South Pacific Seaplanes did not include the aircraft manufacturer’s procedures for a ‘Baulked Landing’ (go-around). Subsection 40.1.0.4.3 of the Civil Aviation Orders (Authority Given By Class Endorsement) provided the following: ‘NOTE 1: The holder of a class endorsement should not act as pilot in command of any aeroplane included in the class on any flight unless he or she is familiar with the systems, the normal and emergency flight manoeuvres and aircraft performance, the flight planning procedures, the weight and balance requirements and the practical application of take-off and landing performance charts of the aeroplane to be flown and has sufficient recent experience or training in the aeroplane type, or in a comparable type, to safely complete the proposed flight. ‘NOTE 2: The owner and the operator of a type of aeroplane included in a class of aeroplane should ensure that any person who proposes to fly as a pilot in command of the aeroplane complies with the requirements set out in Note 1 and should, where necessary, require the pilot to provide evidence of recent experience or training in the aeroplane type, or in a comparable aeroplane type’. Pilots described the difference between the Cessna 185 and the Maule M7 to be quite marked, in both handling and performance. The Cessna was described as being ‘heavy’ on the controls and having a ‘solid feel’. It demanded of the pilot a greater physical and mental input, which was attributed to a combination of higher control forces and aircraft performance. Its longer take-off run than the Maule’s, and its poorer climb performance, required much more thought and planning. Pilots reported they became more fatigued flying the Cessna than they did flying the Maule. 1.18.6 Airworthiness The relatively small Maule M7, in particular, was adversely affected by continued operations in saltwater and environmental conditions for which it probably had not been designed. That resulted in ongoing airworthiness problems for the company. However, the Managing Director believed that part of the problem was that CASA staff were generally critical about floatplanes, because they did not understand the environment in which they operated. Aircraft operated in saltwater were bound to develop rust streaks and to sustain more severe weathering, but this was part of normal operations. The Managing Director said he was aware that the aircraft needed almost constant maintenance because of the operating environment. However, because the maintenance facilities were located at Bankstown, it meant that company aircraft had to be flown to the adjacent Georges River and transported on a trolley to the maintenance facility at the airport. As a result, minor repairs were difficult to attend to. The Managing Director indicated that CASA had also been critical of the decisions made by pilots when assessing damage and defects on company aircraft. Because of the nature of floatplane operations, small dents and other minor damage were almost daily occurrences. He said that staff would assess the damage to determine if an aircraft could continue to be flown. He agreed that there were generally no entries placed on the maintenance release to this effect, and that CASA had identified that deficiency in an audit. The Managing Director believed this situation would be addressed by South Pacific Seaplanes having its own maintenance facility. 23 At the time of the accident, the Managing Director had taken steps to employ a full-time engineer at the Cronulla base, and to gain CASA approval to carry out maintenance on company aircraft. 1.19 CASA air operator certification procedures 1.19.1 Introduction Section 9 (1) of the Civil Aviation Act 1988 stated: ‘CASA has the function of conducting the safety regulation of the following, in accordance with this Act and the regulations: (a) civil air operations in Australian territory; (b) the operation of Australian aircraft outside Australian territory’. 1.19.2 Aviation Safety Compliance Branch structure Pending implementation of the new CASA organisational structure in July 1998, the structure of CASA prior to 30 June 1998 was comprised of the following; • The Office of the Director, administered by an Acting Director Aviation Safety, who in turn reported to the CASA Board. • Fifteen branches, including the Aviation Safety Compliance Branch, each administered by a general manager reporting to the Acting Director. • The Acting General Manager, Aviation Safety Compliance Branch, was responsible for coordinating entry-control and surveillance functions, developing appropriate processes for centralised management of key aspects of those functions, as well as other compliance and enforcement related activities. Branch accountability for those functions was facilitated at the field level through three regional managers who reported directly to the Acting General Manager. The Acting General Manager stated that he had a staff of two flying operations inspectors and one technical officer to assist him, and felt that this was insufficient to adequately oversee the actions of regional managers. He was provided with delegations similar to those held by regional managers, but no superior delegations. • The role of the regional office was to provide the most efficient means of ensuring industry compliance with aviation regulatory standards, and providing regulatory services. The regional manager was responsible for the performance of district offices within the regional boundaries. District flying operations managers and district airworthiness managers reported directly to the regional manager. • The function of the Office of Legal Counsel was to provide assistance to the Board, the Director, and staff on legal issues involving the operation of CASA. This included providing legal advice on regulatory functions, and assistance in the preparation of regulatory documents such as show-cause letters. In addition the office was responsible for managing Administrative Appeals Tribunal appeals, and other legal issues involving CASA. 1.19.3 Initial issue of an Air Operators Certificate In accordance with the provisions of section 9 (1) of the Civil Aviation Act 1988 CASA has a number of defined functions. For the purposes of its functions CASA may issue Air Operators Certificates (s27 (1) Civil Aviation Act (1988)). Division 2 of the Civil Aviation Regulations lists certain requirements to ensure the safety of commercial operations. 24 An operator is defined in Civil Aviation Regulation 212 as a person who engages in commercial operations. Commercial operations are defined in Civil Aviation Regulation 2. Air service operations for Commercial Purposes are defined in Civil Aviation Regulation 206, including charter purposes (206(1) (b)). Aquatic Air Pty Ltd trading as South Pacific Seaplanes held an Air Operators Certificate (BK535224-07) authorising charter operations, at the time VH-HTS was involved in the accident at Calabash Bay on 26 July 1998. Procedures to be followed by CASA personnel, prior to the issue of an Air Operators Certificate, were described in the Air Operators Certification Manual. Prior to the existence of that manual, the applicable CASA document was the Manual of Air Operator Certification. That document was the governing internal manual when South Pacific Seaplanes first applied for an Air Operators Certificate. 1.19.4 Subsequent issue of an Air Operators Certificate Procedures for the re-issue of an Air Operators Certificate were contained within chapter 1.3 of volume 1 of the Air Operators Certification Manual. There was no provision within the Civil Aviation Act for an existing Air Operators Certificate to be renewed, to have the validity period extended, or to renew an expired Air Operators Certificate. The Act contains a provision whereby the production of new manuals is not required for the re-issue of an existing Air Operators Certificate. However CASA could request the applicant to produce manuals if required. 1.19.5 Compliance statement On 8 May 1997, the district flying operations manager wrote to the then chief pilot of South Pacific Seaplanes indicating that the term ‘renewing’ an Air Operators Certificate was no longer used in legislation so there would be a need for all operators to provide a ‘Compliance Statement’ when applying for the issue of an Air Operators Certificate. It was explained that this was necessary to assist an operator in achieving regulatory compliance, and to enable CASA to verify that compliance. An applicant would need to have in place, or develop, specific procedures to achieve compliance. Such procedures must be included in the operations manual. The letter also stated: ‘You will appreciate that in this post Monarch and Seaview era, satisfactory completion of the Compliance Statement is a pre-requisite for re-issue of your AOC’. On the evidence available, no Compliance Statement was ever produced by South Pacific Seaplanes prior to Air Operators Certificate re-issue. Yet, prior to February 1998, the Air Operators Certification Manual (appendix 4 checklist, Operations Manual, volume 2, version 2.0, May 1997) required the operations manual to be first checked against the Compliance Statement for completeness and acceptability, before conducting further checks of the manual. 1.19.6 Limits on the issue of an Air Operators Certificate Section 28 (1) of the Act stated (in part) that if a person applied to CASA for an Air Operators Certificate, CASA must issue the Air Operators Certificate if, and only if: ‘(a) CASA is satisfied that the applicant has complied with, or is capable of complying with, the provisions of this Act, the regulations and the Civil Aviation Orders, that relate to safety, including provisions about the competence of persons to do anything that would be covered by the Air Operators Certificate…’ Paragraph 2.3.1 (2) of the Air Operators Certification Manual, volume 1, states (in part): 25 ‘The delegate must be either satisfied as to the matters contained in Section 28, or not. Similarly, an operator either complies or does not. Under the Act, a delegate must not issue an AOC for a limited period solely to give an errant operator time to meet requirements.’ (The delegate in this instance was the district flying operations manager.) 1.19.7 Air Operators Certificate cancellation action According to information provided by the CASA Office of Legal Counsel, during the period 1 July 1996 to 31 July 1998 there were two Air Operators Certificates cancelled by CASA. The CASA Annual Report of 1996-97 indicated the total number of Air Operators Certificates in Australia was 910 (not including foreign aircraft Air Operator Certificates). 1.19.8 Operations manuals CASA required an applicant for an Air Operators Certificate to lodge certain manuals, including an operations manual (s27AB (2) (a) Civil Aviation Act (1988)). Civil Aviation Regulation 215 requires that an operations manual be provided to the operations personnel of the operator for their use and guidance. When an applicant for an Air Operators Certificate lodged a copy of the operations manual, CASA laid down certain actions that were to be undertaken in respect of that manual, during the process of approving the application of the Air Operators Certificate. Those actions were set out in the Air Operators Certification Manual. Prior to 1 October 1998, Civil Aviation Order 82.0 (Air Operators Certificates, Application for Certificates and General Requirements) contained references to the operations manual. Subsection 3.3 of that Order required that an applicant for a certificate must (in part) ‘provide to the Authority for its approval an operations manual’… The Air Operators Certification Manual also defined the phases through which the application for the Air Operators Certificate must pass. Activities within the phases were defined. The document evaluation phase contained the following definition: ‘…involves the detailed study of company manuals, for example, the operations manual…’. Many of the references to the operations manual in the Air Operators Certification Manual were ambiguous. The operations manual was either, ‘assessed’, ‘approved’, ‘accepted’, ‘evaluated’, ‘checked’ or ‘reviewed’, depending upon which section was read and what checklist was applied. 1.19.9 Chief pilot approvals – general Civil Aviation Order 82.1 (issue 2, 3 October 1990) required that an operator establish a position of chief pilot and appoint a person to that position. Appendix 1 to Civil Aviation Order 82.0 (issue 2, 3 October 1990) required that a person not be appointed to the position of chief pilot unless that person’s appointment had been approved in writing by CASA. CASA was required to take into consideration several matters before approving a chief pilot. These matters were listed in part 5 to appendix 1 of Civil Aviation Order 82.0. The applicant was required to be assessed by CASA as being suitable; pass an oral examination covering the regulatory requirements; and pass a flight planning, loading and performance examination on the most complex aircraft operated by the operator. In addition to the above, an applicant could be required to undergo a flight test to demonstrate their suitability to hold the position. CASA was required to issue an approval for the person to hold the position and this approval could contain certain conditions. The approval could be given for a period of time or where no time period was specified, and be subject to the person maintaining a satisfactory level of performance. The approval related specifically to the operator nominated in the notice of 26 approval. The approval could be cancelled or suspended at any time if, in the opinion of CASA, the performance of the chief pilot was no longer of an acceptable standard. Unless otherwise approved by CASA, the chief pilot was required to hold at least the minimum qualifications listed in table A to appendix 1 of Civil Aviation Order 82.0. 1.19.10 Chief pilot approvals – South Pacific Seaplanes In the case of South Pacific Seaplanes the applicable experience requirements for chief pilot approval were; • a minimum of 500 hours total flight time on relevant aircraft types; • 9 months experience in commercial operations; and • full-time employment of the chief pilot by the operator. At the time that South Pacific Seaplanes first obtained an Air Operators Certificate it was only operating one aircraft, so the requirements were less (300 hours on relevant aircraft and 6 months commercial experience). From the commencement of operations until the accident, the company had employed a total of five chief pilots. Moreover, an examination of relevant documents indicated that most of them had limited experience in floatplane operations at the time of approval. Only one applicant had previous experience as a chief pilot. Two chief pilots were approved, subject to being supported by an experienced senior pilot acceptable to CASA. 1.20 CASA compliance and enforcement procedures 1.20.1 Overview In accordance with the provisions of section 9 (1) of the Civil Aviation Act 1988, CASA had the function to develop effective enforcement strategies to secure compliance with aviation safety standards. The policy and procedures under which CASA (and the then CAA) was required to carry out its compliance and enforcement responsibilities were found in CASA’s Compliance and Enforcement Manual, which was first issued in February 1995. That manual defines the distinction between compliance and enforcement: ‘Compliance includes voluntary adherence by the aviation industry to the regulatory requirements and activities conducted by the Civil Aviation Authority involving education and counselling… ‘Enforcement action may take several different forms, including suspension, variation or cancellation of licences, authorities or certificates, and prosecution. ‘Officers should generally use enforcement action as a last resort, unless it is obvious that a deliberate breach of the Act or Regulation has occurred. Normally, officers should adopt a graded compliance path to achieve adherence to regulatory requirements, in the first instance involving education and counselling. It is only when these actions are unsuccessful, or a serious or blatant breach of safety requirements occurs, that stronger deterrent action should be considered’. The regional manager was provided with the delegation (Instrument Number CASA 244/97) to exercise powers relating to Air Operators Certificates. Officers were required to have regard to the general guidance and information contained in the Compliance and Enforcement Manual, and were required to be able to justify their decisions. 27 1.20.2 Compliance and enforcement methods Chapter 4 of the manual outlined the methods to be used by CASA to ensure that safety regulation was carried out. The methods available to CASA to achieve voluntary compliance included education and counselling. The manual explained in general terms the purpose of education and counselling. Officers were reminded that they should provide whatever educational assistance was necessary to promote compliance. Informal counselling was to be used to explain a non-compliance and to obtain an undertaking that further contraventions of the safety regulations would not occur. Such counselling should generally only be used where a person had committed a minor, inadvertent contravention. It also suggested that the counselling be recorded on file. It was recommended that formal counselling be used where a contravention, while not serious enough to warrant administrative action, was nevertheless serious enough to be formally recorded in a person’s file. Where voluntary compliance could not be achieved the Compliance and Enforcement Manual detailed several enforcement methods that could be used to ensure adherence to the aviation safety rules. These include the power to vary, suspend or cancel licences, certificates and authorities. In addition, as contraventions of the ACT and the regulations constitute offences against Commonwealth law, they may need to be referred to the Director of Public Prosecutions for consideration. Part 5.3 of the manual detailed the matters that were to be considered when making enforcement decisions: ‘In determining which of the enforcement tools is the most appropriate in a particular case a delegate must consider all relevant matters, including: • All the facts and circumstances of the case • The availability of reliable evidence • Any precedents • The person’s history of compliance’. The checklist contained within that section was to be used by the delegate to arrive at the correct decision. In addition, categories of operation were ranked. Officers were advised that the higher the category of operation the more serious the contravention. The second highest category listed was charter (passenger). Only regular public transport was listed higher. 1.20.3 Informal conference procedures Section 31 (3) of the Civil Aviation Act 1988 provided that any person whose interests were affected by a ‘reviewable decision’ may apply to the Administrative Appeals Tribunal for a review of that decision. New procedures incorporated into the Compliance and Enforcement Manual in May 1996 provided the option for an informal conference to be offered to those effected by decisions. That procedure was designed to: ‘provide persons affected by licence or certificate action with an opportunity to explain, clarify and expand upon the facts and circumstances giving rise to the action, and, in appropriate cases, provide an opportunity for the delegate and the person affected by the delegate’s decision to formulate the terms of an undertaking, in accordance with which the person agrees to take certain remedial or corrective actions, acceptable to the delegate, which may satisfy the delegate that there is no need to vary, suspend or cancel the person’s licence or certificates’. 28 The information sheet sent with a Notice of Proposed Action (Show Cause Notice) to an affected person contained, in part, the following: ‘On the basis of these informal discussions, the responses contained within your written response to the Show Cause Notice (if any), and such other considerations as the delegate may properly take into account, the delegate may ask if you are willing to agree to take certain specified remedial or corrective actions. If you agree to do so, your agreement will be reduced to a written undertaking to be signed by you and placed on your file’. 1.20.4 Graduated response policy The final report of the Commission of Inquiry into the relations between the CAA and Seaview Air contained several recommendations. Recommendation 7 dealt with the term ‘graduated response’ and how in the Commission’s opinion, that concept had outlived its usefulness. It suggested a change to the enforcement policy for the following reasons: ‘The Commission repeatedly observed situations in which the operator was asked for information or assurances, that were then accepted without either investigation or follow-up. That was the approach even when the operator had a clear motive to conceal or misrepresent the truth. Such an absence of skepticism fosters in operators contempt for the regulatory authority’. Recommendation 8 of the same Commission was: ‘The Authority [CAA], through training and instruction of its officers, place greater emphasis on thorough investigation. Information must be checked for its veracity and accuracy. Assurances should be followed up’. 1.21 CASA surveillance procedures 1.21.1 Aviation Safety Surveillance Program The Aviation Safety Surveillance Program had been developed to undertake the surveillance functions set out in section 9(1)(f) of the Civil Aviation Act. The program was a surveillance strategy designed to provide an assessment of the aviation industry’s safety level, identify regulatory non-compliances, and evaluate industry’s responses to correcting identified non- compliance. The Aviation Safety Surveillance Program was a part of CASA’s quality management system, and allowed CASA to plan surveillance in a systematic manner. The priorities assigned to the planning and implementation of the program were as follows: • activities affecting the safety of the travelling public; • organisations or individuals with known indications of higher risk; • scheduled surveillance; and • unscheduled activities. The information gathered during surveillance activities was used to allow CASA to follow up industry compliance matters with appropriate corrective measures. These measures range from education and counselling through to enforcement, involving administrative action or prosecution. The responsibility for planning surveillance activities was undertaken by the relevant district/section managers. In accordance with the provisions of the Aviation Surveillance Safety Program manual, the normal frequency for a periodic flying operations inspection of a non- scheduled charter operator was once every 18 months. The frequency of airworthiness periodic inspections for the same category of operator was once every 24 months. Although there were 29 only two periodic flying operations inspections during the course of South Pacific Seaplanes operations, there were a number of unscheduled inspections as a response to complaints or reports received. 1.21.2 Non-compliance notices and aircraft survey reports A non-compliance notice formed part of the Aviation Safety Surveillance Program and could be issued by CASA whenever a non-compliance with the regulations or orders had been detected. This could be the result of a scheduled surveillance inspection, unscheduled inspection, or any other time that a non-compliance was brought to the attention of either an airworthiness inspector or flying operations inspector. The non-compliance notice form itself had no legal head of power, but was used by CASA to record the number and type of non- compliance. Non-compliance notices were graded in severity from 1 down to 5 for system deficiencies in commercial organisations/operators, with 1 being a non-compliance relating to domestic passenger carrying operations, placing safety at risk. Where a non-compliance related to the airworthiness of an aircraft, an aircraft survey report was issued. When a non-compliance notice was issued, the operator received a copy referring to the regulation(s) or order(s) not complied with. The notice also detailed how the operator had not complied, and provided a section within which the operator was required to indicate the corrective action taken to rectify the situation. That section was then returned to CASA by the response due date indicated on the form. The inspector who issued the non-compliance notice retained a copy, and a further copy was placed on the operator’s file for future reference. A final copy was sent to an administrative section in the district office where information from the non-compliance notice was incorporated into the applicable surveillance control document, before being entered onto the Aviation Safety Surveillance Program database. If the non-compliance notice had not been satisfactorily acquitted by the response due date, the administrative officer in the Aviation Safety Surveillance Program section of the district office contacted the responsible inspector and determined whether a follow-up letter should be sent to the operator. Volume 1 page 5-21 of the Aviation Safety Surveillance Program manual indicated that a non- compliance notice was taken to be acquitted once the corrective action slip was completed and returned to CASA. The non-compliance notice could be acquitted on receipt of other confirmation considered suitable by the inspector, and recorded on file. 1.21.3 South Pacific Seaplanes surveillance reports There were a total of 21 non-compliance notices and two class A aircraft survey reports issued to South Pacific Seaplanes, based on information provided to the investigation team. Of the non-compliance notices, two were grade 1, eight were grade 2, eight were grade 3 and two were grade 5. One non-compliance notice was not graded. Of the nine non-compliance notices issued as part of a safety audit on 21–23 April 1998 (see 1.22), five had not been acquitted on the Aviation Safety Surveillance Program database by mid-October 1998. The assigned airworthiness inspector who issued the notices advised the investigation team that the reason for their non-acquittal was that the responses provided by the operator were unsatisfactory, and that the measures outlined on the acquittal slips had not been completed. The remaining four non-compliance notices were issued by a flying operations inspector and have been acquitted on the Aviation Safety Surveillance Program database. In an e-mail to the leader of the CASA audit team, the inspector advised that the proposed actions indicated on the acquittal forms of three of the non-compliance notices would be satisfactory; however, those actions had not been assessed by 8 May 1998. By mid-October 1998 no evidence had been found to indicate that an assessment was carried out. The proposed action on the fourth 30 non-compliance notice (inclusion of Cessna 185 procedures in the operations manual) was apparently complied with by the issue of a new operations manual on 1 June 1998. However, there was no evidence that the operations manual itself was assessed by CASA prior to the accident on 26 July 1998. 1.22 Summary of significant events The following is a chronological summary of significant events relating to the operation of South Pacific Seaplanes during the period 26 June 1994 to 29 July 1998. This information has been primarily obtained from an examination of company and CASA documents, together with interviews of key personnel. 26/6/94 South Pacific Seaplanes applied for an Air Operators Certificate to permit single engine floatplane charter operations in the Sydney area. 12/9/94 The district flying operations manager issued Air Operators Certificate BK431538-01 to South Pacific Seaplanes to permit charter and aerial work operations in Maule M7 floatplanes. The Air Operators Certificate to remain in force until 31 August 1995. 7/2/95 A complaint was received by the assigned flying operations inspector regarding the operation of South Pacific Seaplanes Maule VH-AEL at Berowra in hazardous wind conditions on 3 February 1995. 18/4/95 The assigned flying operations inspector issued a non-compliance notice after finding damage to the elevator of South Pacific Seaplanes Maule VH-AEL that had not been entered onto the maintenance release for rectification. The aircraft had continued to be operated on charter operations. The elevator was subsequently removed by the chief pilot for repair. The chief pilot was formally counselled by CASA officers on 12 May 1995. 23/6/95 South Pacific Seaplanes Maule VH-AEL was observed by CASA officers to be apparently operated in a dangerous manner at Rose Bay. During a subsequent meeting at Bankstown on 5 July 1995 the chief pilot raised the issue of aircraft having to turn at heights below 500 ft after takeoff, and to conduct a landing from a final approach leg of less than 500 m, due to constraints imposed by the physical characteristics of some alighting areas being used by South Pacific Seaplanes. 4/7/95 An undated hand written record was placed on the CASA flying operations file concerning compliance of the operations manual with the Civil Aviation Regulations and Orders. The record appeared to have been made on or about 4 July 1995 by the assigned flying operations inspector. One item referred to section A6.13, (Operations at Specific Locations). Another, section A1.16, refered to a company ALA register. There was also a reference that authorised landing areas were to meet the recommendations of the CAAP. 31/7/95 The chief pilot was issued with a ‘show cause’ letter from the district flying operations manager concerning the proposed cancellation of his chief pilot approval. This action was taken with regard to the events of 18 April 1995 and 23 June 1995. 1/8/95 The assigned flying operations inspector advised the chief pilot that South Pacific Seaplanes operations into certain alighting areas were contrary to the South Pacific Seaplanes operations manual and Civil Aviation Regulations 166, and were to cease immediately. The chief pilot was requested to amend the operations manual with proposed methods of operating into those alighting areas before any concession against the Civil Aviation Regulations could be considered. 7/8/95 An exemption from compliance with the provisions of Civil Aviation Regulations 166 (1) (d), (f) and (g) was issued to South Pacific Seaplanes by CASA. 31 31/8/95 The district flying operations manager advised the chief pilot that no further regulatory action would be taken with regard to his chief pilot approval, following due consideration of his response to the ‘show cause’ letter. He was also reminded of his responsibilities with regard to the Civil Aviation Act, Regulations and Orders. 31/8/95 Air Operators Certificate BK431538-02 was issued to South Pacific Seaplanes. To remain in force until 31 August 1996. 12/9/95 A periodic inspection of South Pacific Seaplanes was carried out by the assigned flying operations inspector, who made a recommendation that the frequency of inspections be increased. 26/2/96 A surveillance inspection and ramp check were carried out at the South Pacific Seaplanes Cronulla base. Concerns were expressed by the assigned flying operations inspector regarding, aircraft flying low over Cronulla during approach and landing, and the ALA register not containing sufficient detail regarding dimensions, obstacles and climb gradients. The flying operations inspector recommended to the district flying operations manager that the company be directed to operate their aircraft over water at all times when flying below 1,000 ft over a populated area. A Civil Aviation Regulations 215(3) direction to include that procedure in the South Pacific Seaplanes operations manual was subsequently made on 17 April 1996. The flying operations inspector also recommended that the frequency of inspections be increased. 17/4/96 A new Air Operators Certificate BK535224-01 was issued to reflect a change to the company legal entity. To remain in force until 31 August 1996. 18/4/96 The chief pilot of South Pacific Seaplanes complained to the CASA Deputy Director Aviation Safety that a directive issued on 17 April 1996 regarding flight over water below 1,000 ft was too restrictive. 13/5/96 A meeting was held at Bankstown to discuss the flight over water directive. In attendance were the assigned flying operations inspector and the CASA officer who issued the directive, as well as the South Pacific Seaplanes chief pilot, Managing Director, and a representative from the Waterways Authority. 16/5/96 Following the Bankstown meeting the South Pacific Seaplanes chief pilot wrote to the deputy director of aviation safety alleging that the assigned flying operations inspector had ‘consistently obstructed our companies [sic] progress and operations by creating problems and having us re-write and re-word our Operations manual no less than five (5) times since August 94’. 20/5/96 The South Pacific Seaplanes chief pilot wrote to the district flying operations manager indicating that the regional manager had requested that the district flying operations manager be informed that South Pacific Seaplanes did not intend to answer any questions, or enter into any correspondence with the assigned flying operations inspector. In the meantime, the chief pilot stated that the Deputy Director Aviation Safety had confirmed that the directive issued on 17 April 1996, regarding flight over water below 1,000 ft was null and void. 28/5/96 The regional manager convened a meeting between all parties to the dispute regarding flight over water below 1,000 ft, including another seaplane operator. It was resolved that companies needed to consider amending their operations manual to address operations over major built up areas. The issue of complaints against the assigned flying operations inspector was to be addressed as a separate matter. 12/8/96 The district flying operations manager advised South Pacific Seaplanes that the allocation of work in a district office was a matter for the district flying operations manager, who had to make the best use of available resources. The assigned flying operations inspector would remain unchanged. 32 29/8/96 Air Operators Certificate BK535224-02 was issued. To remain in force until 31 August 1997. 11/11/96 The South Pacific Seaplanes Managing Director advised the district flying operations manager of the resignation of the chief pilot. The district flying operations manager advised that until CASA approved a new chief pilot, all operations authorised by Air Operators Certificate BK535224-02 must cease. Later, that day, the Managing Director advised that the chief pilot would remain in his present position. 18/11/96 The South Pacific Seaplanes chief pilot advised the Managing Director that he would be leaving the company on 18 December 1996. The district flying operations manager was advised and indicated that a suitable candidate for the position of chief pilot would need to be assessed prior to gaining approval. 29/11/96 An application for chief pilot approval was sent to the district flying operations manager. 12/12/96 The chief pilot applicant was assessed by a CASA flying operations inspector but was unsuccessful in meeting the knowledge and experience requirements to gain approval. On the following day another flying operations inspector suggested that the current chief pilot remain in that position for a further 2 weeks to enable the incoming chief pilot additional time to gain approval. That suggestion was rejected as the departing chief pilot would be some 2,000 km away from where South Pacific Seaplanes operated. However he subsequently advised the district flying operations manager that he would delay his departure until 2000 hours on 19 December 1996. 19/12/96 The incoming chief pilot reached a satisfactory standard with regard to the deficiencies identified on 12 December 1996. However, his flying experience in floatplanes was still less than that required by CASA. The flying operations inspector recommended that he be made chief pilot subject to a satisfactory resolution of the floatplane experience requirements. 23/12/96 The new chief pilot was formally approved by the district flying operations manager, following the appointment of an experienced floatplane pilot as his senior pilot. 24/12/96 The former South Pacific Seaplanes chief pilot complained to the Managing Director that South Pacific Seaplanes had conducted operations between 20 December 1996 and 22 December 1996 without a chief pilot. 26/12/96 A South Pacific Seaplanes Maule, VH-LRZ, overturned in strong winds at Rose Bay whilst taxiing. The pilot, who was the only occupant, escaped uninjured. The following day the chief pilot suspended flying operations for some hours. 27/12/96 The former South Pacific Seaplanes chief pilot, rang CASA and complained that South Pacific Seaplanes had conducted operations between 20 December 1996 and 22 December 1996 without a chief pilot. 18/2/97 As a result of a CAIR report submitted to BASI on 4 January 1997, CASA was advised that serious allegations had been made concerning the operation of South Pacific Seaplanes. Specific details from that report were included in the advice to CASA, in a de-identified form. 20/2/97 An unscheduled inspection of South Pacific Seaplanes was carried out at Palm Beach by the assigned flying operations inspector, accompanied by a senior airworthiness inspector. A number of deficiencies were found that resulted in four non-compliance notices being issued relating to the operation of South Pacific Seaplanes aircraft. Two aircraft survey reports were issued relating to the airworthiness of Maule VH-AGX. At the time of the inspection, that aircraft was being operated by the chief pilot on a passenger carrying flight. 21/2/97 Further allegations of unsafe operations relating to South Pacific Seaplanes were received by BASI in a CAIR report, and subsequently referred to CASA in a de-identified form. The CAIR manager was satisfied that the substance of the claims warranted further investigation. The 33 concerns related to the apparent lack of ability demonstrated by the pilot of a South Pacific Seaplanes Maule. 13/3/97 Following information passed to CASA from BASI (Sydney Field Office) on 13 March 1997, the regional manager requested that the district flying operations manager investigate allegations that South Pacific Seaplanes operated without an approved chief pilot, and recommended that, if true, the company be asked to show cause why their Air Operators Certificate should not be varied. 19/3/97 The former South Pacific Seaplanes chief pilot wrote to the Deputy Director Aviation Safety regarding the safety of South Pacific Seaplanes operations. He indicated that he still had some unresolved concerns with the company, which he had reported to the CASA Bankstown district office, and to CAIR, with no apparent result. He alleged that he had received complaints from company pilots concerning ‘flying over-weight and out of balance, being forced to fly in conditions exceeding the capabilities of the Maule, exceeding flight and duty times each week and the lack of experience and control exercised by the Chief Pilot’. The writer also alleged that the current chief pilot had telephoned him four times to complain of the same things, advising that ‘he has