Barry Hempel Inquest

[Up-into-the-air]

casa involvement in Hemple

Careful reading of the Coroner's finding reveals some gems:

1. REPRESENTATION:
   Counsel Assisting: Ms Karen Carmody
   Samantha Hare & family of Ian Lovell: Mr Ken Fleming QC i/b Kerin Lawyers
   Civil Aviation Safety Authority: Mr Ian Harvey
   Dr Sheahan, Dr Lam & Dr Spall: Mr P Hastie i/b Ashurst
   QBE Insurance: Mr A Katsikalis i/b Carter Newell
   Mr Craig: Mr A Mansfield
2. The Yak was designated as a ‘limited category aircraft’ in that the design manufacture and airworthiness were not required to meet the standards of the Civil Aviation Safety Authority (CASA). The Yak was regarded as a Warbird and as such it was less stringently operated and administered than normal passenger carrying aircraft.
3. CASA schedule of regulatory action & criminal proceedings [45 charges/ proceedings] instigated against the late Barry Hempel for breaches of Aviation Legislation;
4. Hempel’s Aviation Pty Ltd, also had an extensive history of breaches of both administrative and flying regulations;
5. His Commercial Pilots Licence (Aeroplane), his Transport Pilots Licence (Aeroplane) and his Commercial Pilots Licence (Helicopter) had all been cancelled by CASA;
6. CASA was, therefore, well aware that Mr Hempel was a pilot who flew with a total disregard for the safety regulations enacted to protect the public, passengers and the aviation industry generally;
7. Mr Hempel was not authorised to take fee paying passengers;
8. It became evident that no-one, other than Mr Hempel and CASA, knew what licence he held;
9. Given the litany of Barry Hempel’s breaches, one is left wondering why CASA allowed him to continue flying;
10. It was the evidence of the officers [QAS] that in their opinion, Barry Hempel had suffered an epileptic seizure [in 2002]. This was clearly marked on the report which was provided to CASA;
11. At the inquest Dr Maxwell was shown the ambulance report in relation to the events of October 2002 which had been in CASA’s possession. He said this was the first time he had seen that document;
12. Dr Maxwell said he had to rely upon that which Barry Hempel told him, and for the purposes of the report he was never supplied with the ambulance report by CASA. Had he been so supplied, he said he would never have recommended Barry Hempel’s licence be returned;
13. In relation to a diagnosis of epilepsy, Dr Cameron was most emphatic, an AV-MED doctor must notify CASA then it’s up to CASA to consider the person’s licence;
14. He replied - ‘Based on this report, I would still, if he was a pilot, I would say you can’t fly. I would notify CASA I would then do a neurological assessment an examination with EEGs and MRI et cetera.’
15. Dr Cameron went on to say that it is up to the pilot to notify CASA as well. In summary, Dr Cameron said - ‘I don’t ground him. I say he can’t fly. CASA grounds him.’
16. Notwithstanding his clinical suspicions, Dr Spall failed in his duty as an av-MED doctor to advise CASA that he had his reservations concerning Barry Hempel’s epilepsy and that he had in fact prescribed Tegretol to him.
17. During the inquest it became apparent that Dr Spall was aware of at least two instances after the accident with the hangar door, which could have been put down as epileptic episodes, and he failed to communicate his concerns to CASA;
18. Witnesses from CASA Aviation Medical Branch including Dr Tak Shum and Dr Liddell both agreed that CASA received a copy of the QAS report dated 29 October 2002;
19. This document ought to have put CASA on red alert as to Barry Hempel’s ability to fly. It is unbelievable that CASA did not act;
20. During the inquest it became obvious that CASA medical officers were cavalier in respect to the QAS reports of both 1 July 2002 and 29 October 2002, and notwithstanding the opinions of Dr Maxwell and Dr Cameron in relation to ambulance staff and paramedics generally, CASA medical officers chose to disregard the observations of trained paramedics;
21. The fact that CASA did not test the truthfulness of Barry Hempel’s assertions and withdraw his licence after a due and diligent enquiry proved absolutely disastrous;
22. A further disturbing aspect of the case is internally, CASA had been on notice as to Barry Hempel’s medical condition and that it required further investigation, and
23. That notice had been included in a report provided to CASA by Mr John Jones, a CASA investigator;
24. It is of concern that the Australian Traffic Safety Bureau (ATSB) chose not to investigate the crash;
25. This concern is compounded by the fact that CASA commenced an investigation but does not seem to have concluded it and no formal or informal report into the incident has been provided to the inquest;
26. It appears that the Queensland Police Service (QPS) is responsible for the investigation of Civil Aviation accidents/incidents when the ATSB does not attend;
27. Whatever the complexities of an inter-agency investigation and the delineation of which entity had the responsibility for investigating an incident, it seems that, in reality, it fell between the cracks;

Recommendations Re CASA by the Coroner:

1. That CASA consider immediately disseminating the names of pilots to the industry who have had conditions imposed upon their licence or had their licence suspended or cancelled. As it is a matter of some urgency, the dissemination should be by way of emails.
2. That CASA consider immediately introducing a Register of Pilots which includes reference to licence suspensions and cancellations. That further dissemination
   Findings of the inquest into the death of Barry Hempel and Ian Lovell 16
   Findings of the inquest into the death of Barry Hempel and Ian Lovell 17
   should be by way of, a readily available entry on the CASA website in the form of the Register of Pilots, in the CASA briefing newsletter and the bi-monthly electronic magazine ‘Flight Safety Australia’.
   (a) The fact that the Register exists should be published as widely as possible and on an urgent basis so that all pilots, airports and related aviation industry members are alerted to its existence.
   (b) In the event that concerns are raised by CASA with respect to privacy or confidentiality requirements CASA should be referred to a range of entities which have long published such Registers.
3. That when investigating a pilot’s medical fitness CASA should consider adopting the practice, in the event of becoming aware of an ambulance/paramedic attendance upon the pilot, of obtaining the ambulance/paramedic report and related hospital reports. Where relevant they should also speak to the author of such reports. Those reports should also be forwarded to that pilot’s Aviation Medical Examiner.
4. That CASA give consideration to a review of the ‘culture’ within its Medical Unit of accepting medical information provided by pilots rather than being cautious, in particular with respect to pilots who are at risk of losing their licence.

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The above is a summary of what casa was up to in the Hemple case - enough "....holes in the green cheese to line up again and cause a fatality...."