CASA failed to investigate complaints of poor practices at charter operator before crash

Complaints from pilots about unsafe conditions at a charter flight business were not properly investigated by the Civil Aviation Safety Authority, a damning ATSB report on a serious crash has found.

The aviation safety regulator failed to properly investigate claims a West Australian charter operator was making its pilots fly unsafe aircraft, even after a serious crash.

The damning finding against the Civil Aviation Safety Authority is among several concerns identified by the Australian Transport Safety Bureau in its report on a Broome Aviation crash at Derby in 2023.

A young pilot was badly hurt when the Cessna 310R he was flying ran out of fuel 5km short of Derby Airport, and then crashed into bushland as he tried to land on a highway. His passenger escaped serious injury.

The final ATSB report found the pilot was not familiar with the aircraft’s relatively complex fuel system after transitioning from a Cessna 210 and getting little supervision or support from employer Broome Aviation.

Further findings were made that current and former pilots of the company had raised concerns about pressure not to report aircraft defects and to continue flying planes they considered unsafe.

A complaint of this nature was made to the Civil Aviation Safety Authority prior to the 2023 crash, but the ATSB found it was not properly investigated because no pilots were interviewed.

“On this occasion, it appears an important opportunity was missed,” said the ATSB report.

The wreckage of the Broome Aviation Cessna 310R. Picture: WA Police.

Two more complaints to CASA after the crash were similarly poorly handled, the report found.

“There were multiple pilots within the organisation who could have provided valuable insights given their extended time and familiarity with the operator,” the report said.

“Engaging with these individuals would have allowed CASA to gather a broader perspective and determine whether the reported organisational issues were systemic or simply reflective of dissatisfaction from potentially disgruntled former employees. As demonstrated during this investigation, there were widespread concerns about these matters within the pilot group.”

ATSB chief commissioner Angus Mitchell said findings against the regulator were not made lightly.

“It’s all very well to make findings in hindsight, and we look at how our findings are likely to lead to a safer system in the future, as opposed to just hammering a regulator because we found evidence to be critical,” said Mr Mitchell.

“We look for evidence that will lead to making recommendations that are going to have a safer system moving forward.”

ATSB chief commissioner Angus Mitchell. Picture: Glenn Hampson/NewsWire

The report also found CASA approved an interim head of flying operations at Broome Aviation six months before the crash, via an abbreviated assessment.

When the HOFO continued on in the role while doing the same job for another operator as well as working as a pilot, CASA did not conduct a full assessment.

“Those positions have some very distinct responsibilities around safety,” said Mr Mitchell.

“If you’re starting to split someone’s focus between flying and other duties and between organisations, then you start to compromise the integrity of what the HOFO is meant to be.”

Since the ATSB investigation, Broome Aviation had addressed the concerns around fuel management systems, training and supervision, and installed a permanent head of flying operations.

“CASA has also advised it will consider the issues of organisational pressure when it conducts its next surveillance event on the operator,” said the ATSB.

Mr Mitchell declined to comment on whether the ATSB’s findings suggested other charter flight businesses could be operating unsafely, with inadequate oversight by CASA.

“One of my roles is to instil confidence in the travelling public in that when things like this do raise their head, they are transparently investigated and reported on,” he said.

“That’s exactly what’s happened in this investigation, as difficult as that sometimes is when you’re investigating the actions of another government body.”

A CASA spokesman said the regulator was “reviewing the ATSB report in detail with a view to applying any relevant safety lessons”.

Originally published as CASA failed to investigate complaints of poor practices at charter operator before crash