Insufficient organisational risk controls implemented by Angel Flight Australia

Australian Transport Safety Bureau

Obviously, our proposed meeting in Brisbane is no longer possible, so please accept my apologies and convey my apologies to Marjorie and Howard.

Just as a reference where we are at in the dealings between ATSB and AngelFlight:

1. The correspondence to date about the Safety recommendation AO-2017-069-SR-015 (The Australian Transport Safety Bureau recommends that Angel Flight Australia takes action to enable it to consider the safety benefits of using commercial flights where they
are available to transport its passengers) has been published on the ATSB website.

This is available at: www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-069/ao-2017-069-si-01/

I understand from our discussions that your Board has met and considered the recommendation further. It might be useful from a public record perspective, for you to consider a clarification of the discussion at the Board level, and the rationale for not accepting the recommendation – this would be published as is our transparency obligation. As discussed, the ATSB has no powers to enforce any recommendation.

2. Safety issue AO-2017-069-SI-02
The ATSB investigation also published a safety issue regarding insufficient organisational risk controls in place by Angel Flight: Angel Flight had insufficient controls in place, and provided inadequate guidance to pilots to address the additional operational risks associated with community service flights.

The ATSB is monitoring the promised safety action, which was:

• Developing on an online introductory course for pilots for community service flying.
• Received permission to provide access to all registered pilots to the Aircraft Owners and Pilots Association US to access the Public Benefit Flying: Balancing Safety and Compassion course. This course is a required prerequisite
  to pilot volunteering for Angel Flight.
• Planning a mentoring program, consisting of two flights to reinforce the culture and provide familiarity with Angel Flight Australia expectations.
• Sharing all Civil Aviation Safety Authority (CASA) safety seminar schedules with pilots on the Angel Flight Australia register, and requesting feedback on attendance and content.
• Requiring physical copies of pilot log books every 90 days
• Engaged a volunteer to write a safety management system (SMS).
• Updated documentation to remove reference to ‘missions’.

As it has now been several months since the ATSB report has been released, as discussed, we would be grateful for a written update on the progress of this safety action. This update will be published on the ATSB website and will form the basis for the ATSB to decide whether to continue monitoring the safety action or close the safety issue. This decision will be based on an assessment of whether safety actions completed to date reduce the safety issue risk sufficiently.

This safety issue is available at:
www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-069/ao-2017-069-si-02/

Angel Flight

The Angel Flight Board has given very careful consideration to both the recommendation and the safety issues included in the report and can now advise our position as follows. We make these responses provisionally, as we have only now had the opportunity to view the latest ATSB accident rate report. On the face of it, the CSF rate is approximately half of that originally reported, and even less when the correct data is used (and not the admittedly flawed BITRE data). The latter reports 1264 total hours flown in the entire sector, whereas our own (validated) database shows Angel Flight alone flew 3042 hours that year. However, we are undertaking further expert analysis to confirm these comparatively low rates, and shall revert to you when these findings are available.

Safety issue AO-2017-069-SI-02

Angel Flight had insufficient controls in place, and provided inadequate guidance to pilots to address the additional operational risks associated with community service flights.

Angel Flight has, since its inception, strived for continuous improvement in all aspects of its work and, especially, in matters related to safety in the air, on the ground and in the office. Immediately after the 2017 accident (and well prior to the release of the report), Angel Flight increased its efforts to address the safety issues that became apparent from the accident.

The status of each of the actions identified by Angel Flight, and referred to in the report and your email, is described below.

• Developing on an online introductory course for pilots for community service flying. 
  Completed. 
  All new pilots and drivers are required to complete the relevant induction course before applying for their first flights or drives. Pilots who have not flown for Angel Flight for more than 12 months must also repeat the course.
• Received permission to provide access to all registered pilots to the Aircraft Owners and Pilots Association US to access the Public Benefit Flying: Balancing Safety and Compassion course. This course is a required pre-requisite to pilot volunteering for Angel Flight. 
  Completed. 
  All new pilots are required to complete the AOPA course before applying for their first flights.
• Planning a mentoring program, consisting of two flights to reinforce the culture and provide familiarity with Angel Flight Australia expectations. 
  Completed.
  Implementation was delayed while seeking clarification from CASA on the restrictions imposed by CASA Legislative Instrument CASA 09/19. While a degree of uncertainty remains, the program is in use. All new pilots are required to complete at least two mentoring flights before conducting their flights as pilot in command.
• Sharing all Civil Aviation Safety Authority (CASA) safety seminar schedules with pilots on the Angel Flight Australia register, and requesting feedback on attendance and content.
  Completed.
• Requiring physical copies of pilot log books every 90 days.
  Alternative strategy completed.
  Angel Flight considered that requiring physical copies every three months would be an unnecessary and unwelcome imposition on pilots who are already required to affirm, before every flight, that they meet all of the relevant requirements specified in CASA Instrument 09/19 and Angel Flight’s other requirements. Angel Flight is currently upgrading its flight coordination software to incorporate automatic checks of pilot documents and other parameters that will circumvent the need for physical copies.
• Engaged a volunteer to write a safety management system (SMS).
  Completed.
  Angel Flight has an active safety committee that meets quarterly and otherwise as needed.
• Updated documentation to remove reference to ‘missions’.
  Not completed.
  Angel Flight reaffirms its decision not to implement this action. All Angel Flight organisations in USA use the term “mission”. Angel Flight West, the largest Angel Flight organisation in USA, has debated its implications and concluded that its pilots recognise that the term does not imply a mandate, in the military sense, that a flight must be completed. Angel Flight Australia agrees.

Australian Transport Safety Bureau

Regarding the second safety issue, the ATSB acknowledges that Angel Flight have undertaken a number of measures to add risk controls to its operation and introduce more guidance for its pilots. 

While some appear well designed, the ATSB encourages Angel Flight to continue to evolve these controls.

The ATSB acknowledges that Angel Flight has developed guidance, available through an online course, and facilitated access to the US AOPA course, which includes references to decision making, weather, communications and flight planning, in relation to community service flights. These actions raise awareness of the additional operational risks associated with community service flights. 

It is noted that a mentoring program has been implemented. 

The ATSB notes that mentor pilots are chosen based only on flying experience and the number of Angel Flight flights undertaken, with limited support or information provided to mentoring pilots to support them in effectively mentoring new pilots or ensuring consistency amongst either the mentor group or new pilots. The ATSB encourages Angel Flight to continue to develop the mentoring program.

The ATSB also acknowledge that Angel Flight has implemented a Safety Management System (SMS).

The ATSB encourages Angel Flight to continue to evolve the SMS, as it is still maturing, noting that the SMS has limited policies and procedures to identify or manage operational risks identified in this investigation. The main risk controls implemented are hazard and incident reporting, and internal auditing. The ATSB notes there is no guidance provided as to what is required to be reported to Angel Flight. Further, the SMS states that 'Angel Flight’s approach will be non-punitive (where possible)' without defining any just culture policy to support this. The ATSB considers this may discourage reporting, not only to the organisation but to other independent bodies, including ATSB. Further, the SMS states that records associated with a hazard or safety incident 'may be destroyed:
(a) two years after actions have been implemented to prevent the hazard and no recurrence of the hazard has occurred; or
(b) the aircraft, motor vehicle, pilot or driver to which the hazard or incident referred is no longer registered with Angel Flight; or
(c) after the type of operation to which the hazard or incident referred is no longer conducted by Angel Flight.'

The ATSB notes this has the potential to prevent the identification of trends over time, counter to the purpose of capturing the information.