Safety issue

Safety issue description

AGAIR management exercised ineffective operational control over the line scanning activities. As a result, the ongoing intermittent pressurisation defect was not formally recorded, the issues with the aircraft were not communicated to the AGAIR safety manager, and the hazardous practice of operating the aircraft at a cabin altitude that required the use of supplemental oxygen, without access to a suitable oxygen supply, was allowed to continue.
Issue number AO-2023-053-SI-04
Issue owner AGAIR
Transport function Aviation: General aviation
Issue status Open – Safety action pending
Date issue released 19/06/2025
Issue status justification

Implemented actions do not address, in full, the matters raised within the safety issue.

Safety action

Action type Proactive action
Action number AO-2023-053-PSA-03
Organisation AGAIR
Action description

AGAIR stated that it has ceased line scanning activities. AGAIR also stated that the organisation’s exposition has been amended to address the matters raised within the safety issue. This included the insertion of the following information:

  • the AGAIR exposition amended in Vol 1, 1.3.5.2 and 1.3.6.2 to include the following statement;
    ‘The HOFO [(head of flying operations)] may delegate any of their responsibilities to other members of the Company however this does not absolve the HOFO of the responsibility. The HOFO must ensure that the person has sufficient knowledge and experience to perform the delegated role. The CEO [(chief operating office)] shall ensure a [notice] is issued via Air Maestro advising staff of the shared responsibilities and the timeframe to which this will occur.’
  • the AGAIR exposition Vol 6, 6.2.10 amended to include the following statement;
    ‘When operating pressurized aircraft, the cruising altitude must be no higher than required to ensure the cabin altitude as displayed on the pressurization controller does not exceed 10,000 feet’.
  • the AGAIR exposition Vol 2, 2.19.3 amended to include the following statement
    ‘On completion of the days flying the Pilot-in Command is to ensure that the days total flight time is logged together with the aircraft’s total time in service, number of landings and engine cycles as appropriate, and cabin differential pressure where applicable. The fuel and flight log is included within the maintenance release folder and forwarded to flight operations monthly for review by the HOFO. Any daily variations noted by the PIC are to be reported to the HOFO while any trend variance from previous figures will warrant investigation and reporting to the Safety Manager. Any maintenance action shall be initiated via the HAAMC [(head of aircraft airworthiness maintenance control)].’ 

AGAIR advised the ATSB that the ‘aircraft daily fuel & flight log’ has been amended to include a column to record the cabin differential during pressurised cruise flight.

AGAIR has also incorporated ‘pressurisation system failure’, ‘oxygen system failure’, ‘hypoxia’, and ‘any hazards unique to multispectral imaging/line scanning operations’ into the organisation’s hazard register. 

Additionally, AGAIR advised the ATSB that it has made changes to its recruitment process.
ATSB response

While the ATSB recognises the changes implemented by AGAIR to date, the actions taken do not address, in full, the matters raised within the safety issue relating to effective operational control. The HOFO was responsible for ensuring the operation was compliant with aviation legislation and conformed to company standards. However, the ATSB found multiple instances where these requirements were not met. The response from AGAIR does not address how the organisation intends to assure future legislative and procedural compliance by line pilots and management personnel.
Action status Closed

Safety action

Action type Safety recommendation
Action number AO-2023-053-SR-01
Organisation AGAIR
Action description

The ATSB recommends AGAIR initiates an independent review of their organisational structure and oversight of operational activities to assure ongoing effective operational control by management.
Action status Monitor

Organisation response

Date received 16/09/2025
Organisation AGAIR
Response text

AGAIR accepts the recommendation in whole and has taken the following actions up to date and continuing to assure ongoing effective operational control by management.

During the last two years the AGAIR CEO has taken on advice and recommendations from industry experts and others to review its organisational structure on an independent basis.

The response and feedback has initiated the following changes within the AGAIR business model.

Changes to the Management Structure are as follows:

  • The role of HAAMC is being carried out by an independent contractor.
  • Oversight for all maintenance activities is being conducted through an independent Continuing Airworthiness Maintenance Organisation (CAMO).
  • An alternate HOO, HOFO and HOTOC, approved by CASA, is being mentored into the primary roles of Head of Flying Operations and Head of Training and Checking.
  • An independent contractor is engaged to manage documentation and compliance between CASA and AGAIR to maintain impartiality during the process of developing policy and procedure with CASA and other regulators.
  • The independent contracted safety management group have expanded their safety management team and are providing additional oversight and support to the Safety Manager and administration support team.

Changes to streamline operations are as follows:

  • The aerial firefighting component of the business has been divested to another organisation, along with AGAIRs aircraft that support that operation, including the Twin Commander aircraft type.
  • This change reduces the number of aircraft it operates from fifteen to five and reduces the aircraft types to two. The only aircraft types which will be operated into the future are Airtractor 802s and Cessna Citation 525s.
  • The AGAIR Exposition and Standard Operating Procedures and manuals have been reviewed by an independent expert, updated and re-written where required to reflect the changed AGAIR operating model.
  • AGAIR has ceased its Part 141 training activities and is contracting the training and checking requirements to experienced and independent flight instructors and examiners.
  • All aircraft maintenance requirements are contracted to approved MROs who in turn are audited by the Safety Committee with oversight from the CAMO to confirm their capability and capacity to meet AGAIR requirements.
  • AGAIR Maintenance has ceased performing aircraft maintenance activities.

These changes have reduced the operational size of the business and introduced new team members across all management sectors. Furthermore, it has brought independent industry contractors with multi-facetted aviation experience into AGAIR management and operations. 

Implementation of this type of oversight has been occurring for more than a year now and is demonstrating assurance of ongoing effective operational control by management.
ATSB response

The ATSB has reviewed AGAIR’s response to the safety recommendation and provided the organisation with the following observations:

  • The response does not state that the organisation has conducted a review as per the ATSB recommendation, rather that the CEO has taken ‘advice’ and ‘recommendations’ over the preceding 2 years.
  • The response contains no information regarding the parties who supplied ‘advice’ and ‘recommendations’ to the CEO, or when these activities took place. 
  • There is no evidence provided to support the actions listed within the response.
  • The response states ‘the aerial firefighting component of the business has been divested to another organisation, along with AGAIRs aircraft that support that operation, including the Twin Commander aircraft type’. The organisational and regulatory outcome of this divestment is not articulated within the response. As of 3 December 2025, the CASA register states that sistership VH-LVG is owned and operated by AGAIR Logistics.

The ATSB has also requested that AGAIR provide the following information:

  • Evidence that an independent review of the ‘organisational structure and oversight of operational activities’ has been conducted. This should include information about the entity/party engaged to undertake the review and a copy of the resulting report and recommendation(s).
  • Evidence that the actions taken in response to the review’s recommendation(s) have been completed, or that an action plan has been developed and implemented.
  • Information on the operational and regulatory outcome of the ‘divestment’ of the aerial firefighting component of the business.

The ATSB will monitor this safety recommendation until a response that satisfies the above issues has been received.
ATSB response date 11/12/2025