On 4 February 2001 the deceased was the pilot of an aircraft VHBBI a Cessna 210. He was to complete a charter from Lake Evella to Elcho Island on the afternoon of 4 February.
The deceased had never piloted the aircraft known as BBI until he assumed command of it that afternoon
The deceased took control of the aircraft without conducting a pre-flight inspection of it; notwithstanding that Darryl Stace had not completed the daily maintenance report.
Mr Stace had not completed the maintenance release report for the 3rd or the 4th of February. In those circumstances the deceased should have conducted his own check of the aircraft and satisfied himself that there were no outstanding defects so as to render the plane unsafe. Again referring to the stall warning device my understanding is that it can be easily checked whilst on the ground, and whilst in flight provided the checking is done at a safe height.
the deceased did not undertake a normal take-off, rather that he gathered speed quickly and kept the plane low to the runway preparing the aircraft for flight. That is he lifted the undercarriage very close to the ground and probably reached a speed of about 100 knots at the end of the runway before he caused the aircraft to ascend very steeply.
the aircraft climbed very steeply to a height of about 400 - 500 feet, at which stage the aircraft stalled. It then pivoted and descended almost vertically towards the ground albeit that before impact some recovery had taken place.
I am satisfied from the evidence that has been adduced at the inquest that mechanical failure did not contribute to this accident.
no entry had been made in the daily maintenance release relating to BBI that the stall-warning device did not work.
The pilots employed by Air Frontier Pty Ltd at the time of this accident were not paid unless they were flying; and they were paid by the hour to fly. They also received in addition to this hourly flying rate a small retainer, so in the words of Mr Hunt junior "they could survive". It may be that the circumstances of their employment arrangements put pressure on the pilots not to enter defects in planes that they became aware of, particularly those that rendered a plane grounded. It may also be that because the 100-hour service was imminent that the defective stall-warning device was not recorded as defective in the daily maintenance release
The deceased for whatever reason attempted an aerobatic manoeuvre for which he was not trained and for which the aircraft was not designed. Its instrumentation was designed for "normal" flight, not unusual flight. Whether the stall warning device would have sounded during the manoeuvre and whether the deceased would have had time to react to it or not is problematic.
Air Frontier Pty Ltd and their operations were questioned by counsel for the family and both Mr Hunt senior and Mr Hunt junior gave evidence. … Young pilots are employed not within the general aviation award, but on a verbal contract paying them hourly for their flying time. They are expected to live in remote communities in what can only be described as substandard conditions. I do accept that the accommodation at Lake Evella was all that was available, however, that does not make it appropriate.
At the time of this accident the pilots at Lake Evella were young and relatively inexperienced. They had chosen aviation as their respective careers and were flying as much as they could to get up their hours to move on. They were doing their apprenticeship.
Evidence was given at the inquest about a culture of cowboy flying by the "Mooney pilots", as the Air Frontier pilots were known. There was a habit of low flying and the doing of tricks, in fact both Mr Robertson and Mr Stace indicated that they had undertaken aerobatic procedures for which they were not trained. The deceased himself had a reputation for low flying and had told Mr Robertson when he arrived only two weeks before the accident as the newest Air Frontier pilot that "what happens in East Arnhem Land stays in East Arnhem Land". Given that the deceased was the Senior Base pilot at Lake Evella, and to an extent at least responsible for Mr Robertson's training and supervision that evidence is disturbing and corroborative of the cowboy culture.
Air Frontier through its Chief Pilot and Director purported not to know what was going on at Lake Evella and believed that Mr Baxter was performing well. They based this conclusion apparently upon the fact that the accommodation at Lake Evella was neat and tidy whenever the Chief pilot, Mr Hunt visited. All Mr Hunt's visits were scheduled visits, he made no surprise visits so the pilots knew when he was arriving so it is not unusual to expect that they would tidy up their accommodation in anticipation of his visit. No contact was made by Air Frontier with members of the community or anybody else who came in contact with their pilots to check about their conduct and activities. It is difficult to accept that the operators of a charter company in these circumstances would not be aware that young men might, if left to their own devices as these young men were, have some fun and try and extend themselves. Further, given the circumstances in which they were expected to live and work, it is almost beyond belief that they did not know what these pilots were doing. It is clear from the evidence that the pilots knew that what they were doing was wrong, inherently dangerous and not within the charter of their employment or in accordance with their training and knowledge of extant air safety regulations. However, having had the opportunity of seeing Mr Hunt Snr and Jnr give evidence I am inclined to accept that they did not know what their pilots were doing. I note that Mr Hunt Snr is now retired and no longer employed as a Chief Pilot.
… the investigation of this particular accident was made more difficult by the failure of ATSB (Air Transport Safety Bureau) to attend the accident site, at the time, and conduct an investigation. ATSB apparently acting on the advice of others determined that they would not attend the accident because it appeared to be an accident involving pilot error only. The basis for that determination could not be explored as the family may have wished because Mr Heitman the ATSB representative who made that determination was not able to be called to give evidence, because he could not be located. This has deprived the family of the opportunity to test Mr Heitman and ascertain why he formed the view about the accident that he clearly did, without attending the scene or conducting any other enquires[sic] other than telephone contacts with it appears Senior Sergeant Bradley and nobody else. Nonetheless even though Mr Heitman did not give evidence I am comfortable in forming the view that it was an inappropriate and wrong decision and probably not based on any clear direct evidence from any eyewitness to the accident.
It was unfortunate that ATSB did not attend the site of the accident at the time. Notwithstanding I am, as I have indicated, satisfied that a proper investigation did take place and that the circumstances of this accident have been properly and fully investigated. That this happened is largely due to the perseverance of Acting Sergeant Scott Burness, and I commend him for his efforts.
As to how Air Frontier was operating at the time given the circumstances of the Air Operators Certificate and the relationship of Air Frontier Pty Ltd with Mooney Investments/ Mooney Holdings is curious. I will refer the evidence in relation to the status of the company to CASA and invite them to make comment. The issue of the safety of general aviation in the Northern Territory is also a matter that prompts me to forward the transcript of these proceedings to CASA for their information and appropriate action and investigation if necessary. It is beyond the scope of this inquest for me to comment further than I have about the activities of CASA or ATSB or make any findings in relation to them.