ATSB investigation highlights risks of community service flights

Mount Gambier Airport CCTV image of VH-YTM taxiing out to runway 24 at 1018

Source: Mount Gambier Airport

An Australian Transport Safety Bureau investigation has found that community service flights conducted on behalf of Angel Flight Australia have a fatal accident rate per flight that is seven times higher than for other private flights.

That was a key finding of the first analysis to be undertaken in Australia to determine the relative safety of Angel Flight compared to other private flying operations, after a second fatal accident involving the charity in the past decade.

The analysis was conducted as part of the ATSB’s investigation into the collision with terrain of a SOCATA TB-10 Tobago light aircraft near Mount Gambier Airport, South Australia, on 28 June 2017. The aircraft had departed Mount Gambier in poor weather bound for Adelaide, transporting a young person to a medical treatment appointment on behalf of Angel Flight, accompanied by a family member.

Shortly after take-off the aircraft entered low-level cloud (estimated to be about 200 feet above ground level), and the pilot, who was not qualified to fly in other than visual conditions, probably became spatially disorientated, resulting in a loss of control of the aircraft.

Our analysis of the circumstances of this tragic accident highlights that passengers on Angel Flight community service flights, and indeed their volunteer pilots, are being exposed to much higher levels of risk

About 70 seconds after take-off, the aircraft collided with the ground. Both passengers and the volunteer pilot were fatally injured, and the aircraft was destroyed.

“The ATSB considers that the conduct of community service flights, where volunteer pilots flying private aircraft to transport those less fortunate requiring medical treatment from regional and rural Australia, demonstrates a laudable concern for others,” ATSB Chief Commissioner Greg Hood said.

“However, our analysis of the circumstances of this tragic accident highlights that passengers on Angel Flight community service flights, and indeed their volunteer pilots, are being exposed to much higher levels of risk compared with other types of aviation operations.”

Community service flights operating on behalf of Angel Flight do so as private flights, which the Civil Aviation Safety Authority (CASA) defines as “flying for pleasure, sport or recreation, or personal transport not associated with a business or profession”.

However, the ATSB investigation showed that the rate of safety occurrences, which can be pre-cursors of fatal accidents, was substantially higher for passenger carrying Angel Flight operations than other private operations. This is almost certainly due to pilots operating community service flights on behalf of Angel Flight being exposed to additional operational risk factors.

Accident site, showing the engine and propeller location, the left and right wing impact marks and the main wreckage

Source: South Australia Police

These include the potential for pilots to experience perceived or self-imposed pressures to take on what Angel Flight described as ‘missions’ to fly ill, unrelated passengers (rather than family  or friends) at pre-determined times and locations to meet scheduled medical appointments, rather than at times chosen by the pilot.

“Angel Flight did not pressure pilots to fly in conditions beyond their capability, but some circumstances can lead a pilot to feel pressure anyway, such as the responsibility to fly unrelated ill passengers to meet medical deadlines. This can lead to degraded decision making under high-pressure situations, like when confronted with poor weather,” Commissioner Hood said.

On the morning of the Mount Gambier accident two regional airliner flights into Mount Gambier were delayed due to the poor weather, Commissioner Hood noted.

The ATSB’s analysis determined pilots flying on behalf of Angel Flight were more likely to make operational errors when compared to other private operations, particularly associated with flight preparation and navigation, airspace, runway events, and communications breakdowns. 

“The community could reasonably expect that community service flights would have a level of safety at least commensurate with other private operations, if not higher. However, this investigation has shown that those conducted for Angel Flight are actually less safe than other private operations, let alone charter and scheduled airline flying,” Commissioner Hood said.

Earlier ATSB research has already established that private flying has a fatal accident rate per flight that is eight times higher than commercial charter operations and 27 times higher than low-capacity scheduled airline flying. Further, there have been no fatalities involving a high capacity airliner in Australia in more than 40 years.

“Given the factors identified for the accident at Mount Gambier and previously with another Angel Flight fatal accident in 2011, supported by the differences identified in the analysis of safety occurrences and consistent with findings from investigations of similar organisations in the United States, the ATSB considers that measures must be undertaken to improve existing risk controls,” Commissioner Hood said.

The ATSB commends Angel Flight for initiating some pro-active action on a number of the investigation’s identified safety issues, including developing an online safety course, planning a pilot mentoring program, and implementing a safety management system. The ATSB will continue to monitor the implementation of these and other controls to ensure pilots receive sufficient support and guidance to deal with the additional risks faced by private pilots when conducting a flight on behalf of Angel Flight.

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

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

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

“As a charity established to transport rural and regional people with limited financial means to medical appointments, the ATSB considers that Angel Flight could and should include the fact that commercial passenger flights have a lower safety risk to passengers than private operations as a factor when they are organising flights.”

Commissioner Hood noted that on the day of the Mount Gambier accident, suitable and cost-comparative airline flights were available.

In response to a separate safety issue raised by the ATSB’s investigation, CASA has taken proactive safety action by ensuring community services flights can now be identified separately to other private operations, which will better enable it to identify risks in the sector into the future.

“The ATSB is supportive of the community service flight sector, however, based upon the analysis conducted, it is essential that the controls for risk are strengthened to prevent further accidents,” Commissioner Hood said.

Read the investigation report AO-2017-068: Collision with terrain involving SOCATA TB-10 Tobago, VH-YTM, near Mount Gambier Airport, South Australia, on 28 June 2017 

Last update 14 November 2019