Barry Hempel Inquest

[Creampuff]

So rather than continue on the basis of mere innuendo, why doesn’t someone post copies of the primary material?

The edition of Annex 13 at the link in TW’s post covers amendments 1 to 10 inclusive. The current edition has 3 more: 11, 12 and 13.

What did amendments 11, 12 and 13 to Annex 13 actually say, and when did each of those amendments actually take effect?

(Nobody would be silly enough to mistake the date of an edition for the date of effect of the various amendments, would they….?)

[Sarcs]

Okay Creamy I'll bite here's a link for Annex 13 9th edition with amendment 11 incorporated, which lists the effective date for the amendment as 13 July 2006:
http://www.cad.gov.rs/docs/udesi/an13_cons.pdf

So the next amendment we're interested in is amendment 12, so here is a link for Annex 13 10th edition, which lists the effective date for amendment 12A and 12B as 20 July 2009. However both 12A&B deal with (a) definitions of runway incursion incidents and (b) State safety programs and voluntary incident reporting systems...blahblah.

Which leaves amendment 13 which was effective on 12 July 2010 and was subsequently in edition 10. And this amendment would appear to have dealt solely with Chapter 5 'Investigations'.

http://www.google.com.au/url?sa=t&rc...9nwvRzZ-gld_fg

Anyway I'll let you do the reading and if you still aren't happy well I'll let you track down a Annex 13 9th edition with the amendment 12 incorporated...

[my oleo is extended]

Halfmanhalftautological,

'Ills Of Society' is catchy. Sounds like a mi mi movie about a serial killer or something of that nature. Definitely a horror movie featuring death, destruction, and rape....or is that what's being allowed to happen to G.A?
And,
'Tautology'. That could be the sequel movie to Groundhog Day, except in 'Tautology' every day that you wake up the industry is still copping the same pineappling by that big (R)egulator....then again 'Tautology' sounds like 'Anthology', a pretty good Peter Frampton album!

[Sarcs]

Senior Constable Anderson points the way!

Anyway annex 13 versions aside the writer of the QPS Coroner's report points the way and reveals some serious flaws and possible breaches in both the bureau's and Fort Fumble's obligations to the ICAO annex 13, the TSI Act and the CAA.

1) Despite notified differences to Annex 13 para 5.1 by the bureau in 2011 at the time of this accident in 2008 the bureau were obligated to notify ICAO and investigate this accident. Why they didn't is open to conjecture but the notified difference to 5.1 at the time just does not cut the mustard:

5.1 In respect of ultralights and sport aviation, for example, microlights, gyrocopters, gliders and hang gliders, investigations will be conducted only if benefits to future safety are evident and resources allow for such investigation.

Remarks:

Australia has limited resources for accident and incident investigation and safety studies including database analysis. It is often the case that investigation of incidents or safety deficiencies involving regular public transport aircraft yield greater future safety benefit than investigation of sport aviation occurrences. Priority is given to the safety of the fare-paying public.

And regardless of whether the bureau could justify not investigating this accident (and as SC Anderson points out in his remarkable report) the bureau were still obligated under section 21 of the TSI Act to:

(3) The ATSB must, within 28 days of discontinuing an investigation,

make publicly available, by electronic or other means, a statement

setting out the reasons for discontinuing the investigation.

NB There is no provision within the act to not even start an investigation where there has been a fare paying pax fatality.

2) There is no notified difference to annex 13 para 4.1 in not notifying to ICAO the circumstances of this fatal accident. Yet as this accident is not listed on the ATSB investigation database one can only assume that ICAO haven't been notified.

3) Although there is a notified difference to para 7.1 of annex 13...

7.1 Australia will comply with the standard for the more complex accidents. However, for some less complex investigations Australia does not prepare a Preliminary Report.

Remarks:

The difference arises predominantly in relation to domestic occurrences, particularly those of a less complex nature, where Australia does not prepare a Preliminary Report.

...I would argue that this accident had enough complexities and murky layers to warrant the bureau to at least write a preliminary report but yet again it never happened.

Thank god for the Coroner's benefit that SC Anderson wrote an exemplary report!

Hmmm doing a "Kelpie"...nighty nite!

[halfmanhalfbiscuit]

Sarcs...I would argue that this accident had enough complexities and murky layers to warrant the bureau to at least write a preliminary report but yet again it never happened.

This is an interesting point regarding not investigating as not a priority. Despite Ian having put his trust in Hempel and being a fare paying passenger on a VH registered aircraft under casa approval. But if the ATSB had investigated they may have found the issues with casa oversight. Consequently Pel Air may not have happened?!

You also have the Barrier MD using phrases like 'personal vendetta by casa'. This sounds like bullying and harassment rather than regulatory oversight!

[Kharon]

You could forgive Barrier's DK for being a little confused and a tad angry though, a little old ladies diary and a disgruntled x employee can apparently galvanise aviations new "tough boy" to show a 'no nonsense' approach to these 'rogue' operators. Much robust posturing and muscle flexing for Barrier, yet the same outfit cleared Pel Air back to operations in less than a fortnight (over Christmas). Then there's John Quadrio stood scratching his arse, wondering "why me" when Hempel strolls through a panel of peers and trades on – regardless.

Consistent?; - "Oh yes Senator, we are consistently above the law, beyond reproach and pretty much consistently do as we damn well please so there; and anyway, we all come from the same training/finishing course; – Admin for Reptiles beyond reproach."

Aircraft ? ...– what aircraft?, thought we got the lot.

[Sarcs]

'Passing strange!'

All good points that you make Biccy and Kharon!

HMHB said: This is an interesting point regarding not investigating as not a priority. Despite Ian having put his trust in Hempel and being a fare paying passenger on a VH registered aircraft under casa approval.

NB I also believe (although I could stand corrected) that the Yak-52’ s MAUW is above 2250kg which is an ICAO basic requirement for notifying accidents or serious incidents and submitting a preliminary report to ICAO (reference Annex 13 paragraphs 4.1&7.1).

Perhaps the Coroner and SC Anderson would be interested in how the ATSB listed this accident on PG 6 of the ATSB weekly summary w/e 05/09/2008 (my bold):
http://www.atsb.gov.au/media/27915/aws050908.pdf

Occurrence Date: 31/08/2008
ATSB Reference Number: 200805512
Occurrence Category: Accident
ATSB Investigation: No
Location:Gold Coast Aerodrome, 330° M 28Km
State: QLD
Aircraft Manufacturer: YAKOVLEV
Aircraft Model: AIRCRAFT FACTORIES YAK-52
Operation Type: Private
Operation Sub Type: Unknown
Airspace Type: OCTA
Airspace Class: G
ATSB Summary: It was reported that the aircraft impacted into water. The wreckage was recovered and both POB sustained fatal injuries.

Passing strange (yet again) that the Coroner and Senior Constable are under the impression that this accident was categorised as commercial and that Ian Lovell was a fare paying pax??

Oh and the Coroner might also be interested to know that apparently the "wreckage was recovered"??

Next..part 3 for Questions for the Coroner..remember the next inquest hearing is Monday morning!

[Up-into-the-air]

atsb ans annex 13

Here's the bit sarcs:

Appendix 8 to Chapter 3
Accident and Incident Notification and Reporting Guidance

1.0 Introduction

In accordance with Annex 13 Aircraft Accident and Incident Investigation, States are required to report to ICAO information on all aircraft accidents which involve turbojet-powered aeroplanes or aircraft having a maximum certificated take-off mass of over 2 250 kg. The Organization also gathers information on aircraft incidents considered important for safety and accident prevention. For ease of reference, the term ―occurrence‖ refers to both accidents and inciden

Full read at:

http://vocasupport.com/wp-content/up...rd-Ed-2012.pdf

[Kharon]

Sarcs # 465 –"Perhaps the Coroner and SC Anderson would be interested in how the ATSB listed this accident on PG 6 of the ATSB weekly summary w/e 05/09/2008 (my bold):"

This is what I was trying to get at, by asking where does the Coroner start and finish?

It's naughty that the ATSB is (quite legally) ducking and weaving it's ICAO obligations; it probably cost a fortune to have our unique 'exemptions' drafted and accepted, but is sorting this, or any of the other let's call them 'investigative anomalies' a job for the Coroner ??......

The Coroner is probably aware of the chronology; in 2007 Vaughan was not messing about, there was a strong push against Hempel (Notice to Cancel.etc.). Johns, in 2008 was also serious, but somehow the problems melted away and Hempel was essentially turned loose and managed to gain a lot more latitude than many other similar cases received on a lot less factual, tested evidence. Why? remains a mystery. This should, I imagine, be important to a Coroner. If BH had been 'stopped cold' then, perhaps the event may not have occurred.

Technically, this was a simple, bread and butter investigation. Why did it become an epic, 'stadium spectacular' with a cast of thousands? Do the maths, there was more money spent involving up to 20 CASA and who knows how many ATSB to deny that that the event is in any way significant; certainly more than the cost of a fairly straight forward 'barge lift' of the wreck. It troubles me that there was a lot more spent avoiding the 'issues' than a routine investigation by CASA and ATSB would have ever cost. But again, is this for the Coroner??. I imagine it would be if the 'aviation investigation', such as it was, has been compromised.

The Coroner and a couple of the Counsel seem to pointed in the right direction, despite the 'sotto voce' distractions. The QPS were thanked by the Coroner, his comments on the rest are still in abeyance.

[Sarcs]

Questions for the Coroner (Part three)!

Yes UITA they’re plenty of indicators that Beaker and co have gone to a lot of trouble to subvert their obligations to ICAO. And just like FF they’ve now got the obfuscation in the form of notified differences to Annex 13 down to a fine art.

Which means that although Oz is a signatory to ICAO we are merely paying lipservice to the principles and charter of the Chicago Convention 1944. This appears to be so ATSBeaker can pick and choose accidents/incidents that they investigate or notify purely for fiscal or politically sensitive reasons not for the stated reasons of improving and mitigating risk in aviation safety.

Do we really want our once small but proud aviation safety watchdog to go down the FF path of thumbing it’s nose at ICAO?

Anyway back to the thread…and to perhaps lead on from Kharon’s very insightful post.

Although FF ended up truncating their investigation into the Hempel accident (for as yet unexplained reasons) doesn’t change the fact that as a federal law enforcement agency they are obligated under AGIS 2003 or 2011 to manage, document and adhere to a set standard for an investigation (just like with Pel-Air and dare I say Barrier). This ‘standard’ is referred to throughout the CasA enforcement manual and the SOPs for upholding this standard is apparently contained within flying fiend’s invisible ‘Investigator’s Manual’.

Extracts from the enforcement manual:


“11.5.1.1 Initial steps (pg 11-4 enforcement manual)


If the relevant manager considers that there may be evidence of a breach then the first action to be taken is initiation of the CEP (see Chapters 2 and 3). It is only after discussion in this forum that a request for investigation should be made using form 333.


The tasked investigator will conduct an investigation to provide the Manager EPP with a report and recommendations in accordance with the procedures set out in the Investigators Manual which incorporates the Australian Government Investigations Standards. (Reference 11-4 enforcement manual.)


If a prima facie case exists and prosecution is considered, a Brief of Evidence will be compiled and submitted in accordance with the procedures set down in the Investigators Manual. Alternatively, on consideration of the investigator’s report, the Manager EPP may decide that the issue of an AIN is a more appropriate penalty. This will also be discussed as part of the CEP. (Reference 11-4 enforcement manual.)


11.5.2 Reporting The Investigators/Coordinator Investigations make entries on AIRS, on the ASIS database and on the Enforcement Action Register on the Enforcement Action eRooms.” (Note: This would be as per the AGIS 2003.)


“13.6.2 Staff Responsible

Inspectors.

At any time, where inspectors may be unsure of exhibit-handling procedures, advice should be sought from EPP.

Note: Investigators are also responsible for evidence/exhibits and should refer to the Investigators’ Manual. (reference 13-7 enforcement manual).

Note: For procedures for evidence and evidence handling (for Inspectors) refer to section 13 of enforcement manual. Investigators procedures are contained within the Investigators Manual.”

“3.7.1 Enforcement Policy and Practice Branch (EPP)

EPP is the focal point for linking all enforcement action and the Manager EPP is the contact point for the CEP.

In addition to its role in the development of CASA’s enforcement policies and practices, coordinating enforcement action and the conduct of investigations by investigators appointed under Part IIIA of the Civil Aviation Act, EPP also has responsibility for:

������ Issuing infringement notices

������ Administering the Demerit Points Scheme

������ Monitoring the Aviation Self-Reporting Scheme

������ Monitoring enforcement processes including compliance-related processes such as counselling.

While some CASA Part IIIA investigators are based in field offices, they are tasked by the Manager EPP, through the Coordinator, Investigations, to investigate complex matters that could result in a variety of outcomes, including referral to the Commonwealth Director of Public Prosecutions (CDPP). Because Part IIIA investigators are tasked on a centralised basis, all requests for their investigative assistance must be made to the Manager EPP or the Coordinator Investigations using form 333. Requests for the assistance of a Part IIIA investigator or the conduct of a Part IIIA investigation should only be made on the basis of a prior CEP consultation. (See Sections 3.4, 3.6.2 and 3.8).
Any general questions relating to enforcement matters should be referred to the Manager, EPP.”


“3.9 Requesting the Services of a Part lllA Investigator

The primary purpose of a Part lllA investigation is to establish the facts and circumstances that gave rise to the breach, by the gathering of information and evidence. This needs to be understood when requesting the assistance of a Part lllA investigator.

Requesting the assistance of a Part lllA investigator is NOT an initial step in relation to enforcement. While investigators undertake investigations that may result in referral of briefs to the CDPP, they also help managers in the collecting of information to support other enforcement responses such as administrative action and to support compliance-related action.

Before an investigation is requested, the operational/technical manager must first take part in the CEP to identify what the manager is trying to achieve, and to assess whether the services of an investigator are actually necessary. While investigators in the EPP Branch have specific powers under Part lllA of the Act in relation to entry and seizure of documents and while they may also be more familiar with the gathering of evidence and the investigative process generally, operational inspectors also have the capability to undertake many of the basic tasks of gathering information and evidence. (See Chapters 12, 13, 14 and 15)

Requests for Part lllA investigations are initiated by using form 333 after a CEP Meeting. (See also the flowcharts Coordinated Enforcement Process A and Coordinated Enforcement Process B.”

So questions for the Coroner:

Q/ Are the above requirements and documentation, as per the AGIS, contained within the 6 volumes of information FF passed onto the QPS?

Q/ Where is the CAsA accident investigation report and recommendations from the Part IIIA investigator for this accident?

Q/ Can the Coroner have a copy of the original form 333 (request for a Part IIIA investigator)?

Q/ As the CDPP prosecution against certain managers of Hempels has now been dropped can the Coroner now get a copy of the FF ‘brief of evidence’?

There’s a start…I’m off doing a Sundy Kelpie!

[601]

Johns, in 2008 was also serious, but somehow the problems melted away and Hempel was essentially turned loose

I believe about that time a CASA team from down south conducted an audit and determined the restrictions for the re-issue of the AOC.
One of the restrictions was that BH was not to have anything to do with the AOC or the operation.

[my oleo is extended]

Let me guess, it was the Sydney office who conducted the audit?

[Sarcs]

Let me guess, it was the Sydney office who conducted the audit?

That's gold Oleo! Although it does stand to reason as they are the experts on systems audits...hmm let me guess they brought there own portaloo??

One of the restrictions was that BH was not to have anything to do with the AOC or the operation.

Fat lot of good that did when it came to restricting big bad Bazza!

[TunaBum]

Pilot in fatal crash 'had brain injury'

THE pilot of a plane which crashed in the ocean off the Gold Coast in 2008 had a history of seizure-like symptoms, a coronial hearing was told today.

Barry Ian Hempel flew a Yak-52 Warbird that crashed near South Stradbroke Island in August 2008, killing him and passenger Ian Ross Lovell.

The court was told Mr Hempel suffered a "severe brain injury" in 2001 and in 2002 was taken to hospital by ambulance on two occasions suffering symptoms which could have been seizures.

In 2005 neurologist Dr Ian Maxwell cleared Mr Hempel to fly, but he said he was unaware of his history.

"If I had that ambulance report I would have cancelled his licence immediately," he said.

[my oleo is extended]

It seems the only people unaware of Barry's 'interesting mental health issues' were Fort Fumble and Dr Maxwell!!
Just about everyone in GA around the nation knew about Barry.

Sarcs, did the Sydney office really bring a port a loo or was it a chamber pot (full of course).

[601]

Sydney office

Nope. Higher up the food chain.

[Frank Arouet]

In 2005 neurologist Dr Ian Maxwell cleared Mr Hempel to fly, but he said he was unaware of his history.

I recommended Mr Hemple consult Dr Maxwell after the same Doctor cleared me to fly, (after 8 years on non epalyptic incidence), and follow the same principle of time/and proof of non events. The simple fact was that I had a coma score of 13 + at all times and no documented loss of conscious ability.

Mr Hemple had a head injury that rendered him unconscious after his head was crushed in a large hangar door.

It would appear that Dr Maxwell was not privy to all the evidence.

I would suggest his protected status lay in his previous strange and documented activities which may have relevance to this incident if someone with the power was of a similar mind.

[Jabawocky]

Franks last paragraph

Wooooowwwww there...

I am sure many of us are joining the dots. If you had proof of this, I would suggest there are places for this.....but not here! Well not until tested in court.

Frank...I did not copy and paste just in case you wanted to remove that bit. You may be right or wrong, but thats a big bold move.

[Kharon]

Jabba - I believe Frank is referring to the previous convictions for an 'adventurous' perhaps caviller attitude toward the Regs, which ended up in a court appearance and subsequent conviction. What else could he possibly mean ??

Hempel was 'known' to the authority, but somehow, some way over the 7.75 years period (rough time line below), he managed to stay in business. How is this so ? is a question a reasonable man may ask, particularly if you compare the Quadrio (or James) time line against this:-

Time frame - 4 July 2001. Medical suspended. 18 March, 2008 AAT application withdrawn. (7.75 years: Director changes eight: CP changes 14. (Conservative count, for those inclined to count such things ). 2007 to 2008 was a good year.

10 April, 2007. Voluntary undertaking.

24 April, 2007. Enforceable Voluntary undertaking accepted by CASA.

08 May, 2007. CASA letter – Show cause.

11 May, 2007. Instrument 161/07 (effective 14 May 07). Approval Australian War-birds??? (Anybody assist with this ??? – curious now)....

18 May, 2007 - 27 June, 2007. Series of correspondence between Hempel Legal counsel and CASA re EVU and Show cause conference. etc.....

6 July, 2007 CASA email Anastasi re 'advice'. (Email not included with QPS brief).

13 July, 2007 – 17 Sept, 2007. Correspondence between CASA and Hempel counsel ending with a show cause issued by Peter Johns.

22 August, 2007. Show cause conference.

29 Nov 2007 - Vaughan cancels Pilot licences.

18 March, 2008. AAT appeal application withdrawn by the Applicant – (Hempel).
18 March, 2008. Cancellation of Hempel CPL effective.

There's passing strange, then there's passing weird.....then there's passing wind. (Pooh/wind separator – Checked). You'll own it is a bit of a curiosity.

[Tankengine]

I last had anything to do with him in 1987, he was "known to the authority" a long time before that.