Classification of parachuting operations in the private category did not provide comparable risk controls to other similar aviation activities that involve the carriage of the general public for payment.
Following the accident, general improvements have been made by the APF with regards to the implementation of a requirement for operators to have a safety management system, the employment of full time safety officers for audits, and CASA’s implementation of new regulations for the control of self-administered organisations, such as the APF. In recognition of these improvements the ATSB is closing this recommendation as partially addressed. However, the ATSB supports the Coroner’s position on these matters and agrees that more needs to be done to improve the safety of parachuting operations with paying participants.
The ATSB recommends that the Civil Aviation Safety Authority introduce risk controls to parachuting operations that provide increased assurance of aircraft serviceability, pilot competence and adequate regulatory oversight.
There was insufficient evidence in the report to establish a connection between the accident flight being operated under the private category (i.e., not under an AOC) and the likely causes identified in the ATSB report that led to the aircraft loss of control.
As previously advised to the ATSB, CASA recognises that there should be (and is) a greater level of legislative requirement for the airlift component of parachute operations than of a generic private flight. CASA instrument 239/13 (at the time of the accident, now 06/16) imposed additional requirements as to the conduct of the accident flight, including pilot qualifications and aircraft maintenance requirements. There is a strong implication in the ATSB report that the CASA maintenance requirements may not have been followed in full, however, those requirements exist. Adherence to requirements is always open for consideration but the salient point here is that maintenance requirements were in place and more stringent than if the operator had been a conventional private operator.
Holding an AOC for a particular operation does not necessarily equate with a higher level of safety. It is the standards that are imposed by the requirement of an AOC or are imposed by other means that influence the level of safety of a particular operation. In this instance, parachuting operations were subject to a legislative instrument that facilitated but did not guarantee a safer operation compared to an operation conducted to purely private standards.
In general, aircraft maintenance appears to be a component of this event and the maintenance requirements are the same in this case whether the operator had an AOC or not. Perhaps there would have been potential for surveillance associated with an AOC holder. However, the significant intervals between surveillance activities for many GA operations would likely have precluded the opportunity to prevent this type of event.
The ATSB did not conclude that identified safety issue contributed to the development of the accident involving VH-FRT. That is consistent with its classification as one of the ‘Other factors that increased risk’ based on importance rather than as a ‘Contributing factor’.
With regard to the conduct of parachuting operations, the ATSB has not recommended that they should be conducted under an AOC. What has been recommended is that risk controls similar to those in place for charter operations such as:
be introduced in to parachuting operations. The absence of these risk controls has been identified by the United States National Transportation Safety Board as contributory to parachuting occurrences.
The ATSB notes that a Coronial inquest relating to the accident involving VH‑FRT will be conducted in September 2018. That inquiry will provide a valuable opportunity to further consider this safety issue, including its resolution. As such, it will remain open until the conclusion of the Coronial proceedings.
In response to the ATSB recommendation on the classification of operations the Coroner stated the following:
I note the advent of CASR Part 149 and the suite of proposed regulations relating to general operating and flight rules (CASR Part 91) and parachuting from aircraft (Part 105) are intended to clarify and provide a more robust regulatory basis for the conduct of parachuting activities under the scheme of self-administration presently maintained by CASA. The recommendations of the ATSB that CASA introduces appropriate “risk control” measures in respect of parachuting operations that provide “increased assurance of aircraft serviceability, pilot competence and adequate regulatory oversight” are supported.
…in evidence, and CASA in its submissions, gave assurances that CASA would embrace those ATSB recommendations in the rollout of the new system. Those assurances were subject to the caveat that the clear policy position of the Commonwealth Government was that parachuting operations will not be regulated in the same way or to the same extent as commercial charter operations.
Notwithstanding these assurances, the legislated measures require CASA and the APF to give urgent attention to ensuring a common understanding of the regulatory role of CASA in relation to the ‘airlift component’ of parachuting operations and the limitations of the APF to truly undertake effective surveillance or auditing of that component.
If CASA is to maintain the fiction that tandem parachutists are not to be viewed as passengers in a commercial air operation during the airlift component of a parachute sortie, because they are not seated in a conventional seat on an aircraft (with the consequence that the entirety of the operation is to be viewed as ‘private’) it is imperative that CASA ensures that the risks of rejecting the AOC system are minimised to the greatest extent possible.
Strengthening the test for accreditation as a “fit and proper person” and putting in place training and checking systems, pilot supervision under a clear ‘chain of command’, operations manuals, safety management systems that provide for pilot-to-pilot consultation on air safety matters and regular compliance checks are arguably appropriate for all air transport operations, including the airlift component of adventure aviation activities.
The Coroner made specific recommendations in the area of risk controls for parachuting operations, they were as follows:
I recommend that the APF revise its policies and procedures for the assessment of whether candidates for and holders of the position of Chief Instructor and others in control of parachuting organisations are ‘fit and proper persons’ and of ‘good repute’.
I recommend a thorough review of the requirements of the CASA-approved APF Jump Pilot Manual, and its suitability for providing appropriate risk-based standards for all air operations conducted by APF club members.
I recommend that CASA and the APF review the implications for public safety of low-time or part-time jump pilots flying sorties in aircraft owned by APF club members and organisations not controlled by persons with the background and experience of an AOC operator. Issues that should receive particular attention include:
(a) the level of training that jump pilots should be receiving and the introduction of specified and appropriately rigorous standards that would apply to jump pilots conducting flights transporting tandem parachutists to the point of departure from the aircraft;
(b) The need for more regular proficiency checks of jump pilots with a qualified examiner, in accordance with a checking syllabus approved by CASA where the syllabus would focus on matters germane to the airlift component of flights carrying tandem parachutists;
(c) The creation of a new operational rating or endorsement with special attention to moulding or expanding the application of the general competency rule contained in regulation 61.385 of the CASR to jump pilots to ensure a far higher standard of airmanship by jump pilots than is presently required; and
(d) Surveillance of the ‘airlift component’ of parachuting operations by CASA flying operations inspectors on a regular or systematic basis accompanied, where resources permit, by area safety officers of the APF.
The Queensland State Coroner supported the ATSB’s findings and the recommendation for increased risk controls for parachuting operations. The Coroner also made recommendations based on the information provided during the Coronial inquest. They included recommendations for improvements in key personnel approvals, operational risk controls, increased pilot experience requirements and increased direct surveillance of parachute operations by CASA in conjunction with the APF.