Barry Hempel Inquest

[004wercras]

Leadie, the relationship between Vaughan and Quinn could only be described as parlous! But it was fun to watch!!
I doubt the Gov'ment would permit the return of Collins, something to do with Lockhart, but I'm not going to start on that again.
Vaughan could be a potential return, he didn't leave CAsA because he wanted to, he couldn't work with the drunk. But I don't think GA would be happy with him returning either.

What to do what to do? I know that a lot of sponsors wanted Carmody (Wingnut) to be DAS rather than the Skull, but the vote, so to speak, went in favour of the Skull, just. Now Wingnut is still out there working in bureaucracy land so you never know, he could come back.

[Kharon]

I'm not hanging on for any response – it's been waaaaayyyy to long. There are too many vested interests, too much to hide and the process was so very neatly diverted to matters 'medical' by Harvey that the best we can hope for is the coroner does not support tightening the screws on pilot medicals; or, having us all micro chipped.

CASA will adopt that form recommendation; it may be the first and only coroner recommendation in history adopted; but if it suits --

Not one to give up easily; but I fear 'flogging a dead horse' is an appropriate idiom. Expecting the worst while hoping for the best.....

[LeadSled]

But I don't think GA would be happy with him returning either.

004,
And why would that be??

He always enjoyed excellent relations with all the alphabet soup orgs., he introduced a number of changes all the GA's benefit, and quarantined some of the worst of CASA's worst to back rooms --- all subsequently let loose on the industry again by the present management.
He was responsible for the change that pulled the rug out from under the "data approval" industry, a nice little earner for those around that little trough ---- and recently reversed by the present management. He was moving towards making Schedule 5 a real maintenance program, as per FAR 43, Appendix D --- all anathema to the "iron ring".

I can't think of a single thing he did that was not to the advantage of the industry. After all, he came to aviation from GA - his first job was with Bob Hoover.

His greatest crime, as far as the CASA "iron ring" was concerned, was that he didn't follow the policy of "maximum conviction at any costs, guilty or not". Unusually for CASA, he didn't believe the accusation was the proof of the crime, he wanted real evidence, he didn't believe in the reverse onus of proof.

After all, his experience of "typical" CASA, before he took a contract with CASA, was of the dictatorial behavior of misinformed, inflexible and aggressive behavior of the little martinets all to typical. I believe he would have been no friend of the ALAEA.

Byron hired him as a change agent, he and Byron were never forgiven for that, as you may well know.

Tootle pip!!

[Bedderseagle]

Coroner's Recommendations from Inquest

Finally, we have a date for the coroner's recommendations from the Inquest. After waiting and waiting, a sudden announcement and its on this Friday 4th October at 10am, Coroners Courtrooms.

Could this be the beginning of the end - I won't hold my breath on that.

[halfmanhalfbiscuit]

bedderseagle,

Thanks for posting the update. This has been a long time coming.

[Up-into-the-air]

Hemple and the Brisbane Coroner Verdict

It will be an interesting listen this morning I wonder if FF will run interference like
they did at Lockhart River???

[Frank Arouet]

OUR ABC reports findings damned CASA and recommends action toward Av MED Branch. Hemple had a seizure from reports. (imagine that).

[TWT]

Death crash pilot 'shouldn't have flown'

[Cactusjack]

Perhaps 4 Corners will investigate who Hempel knew at CASA, what medical practitioners he had trained to fly, who signed him off as medically fit, and who signed off on his pilots licence at CASA?

[Sarcs]

Findings released CAsA dodge a bullet!

Very interesting...

Hempel Coroner Report

Recommendations RE CASA

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 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.

Commonwealth centralised medical treatment system

5. That the Queensland government give consideration to participating in the Commonwealth centralised medical treatment system (eHealth). That systems records medical data including personal health records, Medicare data, Australian Organ Donor Registration data and Australia Childhood Immunisation Registry data which can only be accessed by medical practitioners. Further consideration should be given to a requirement that Queensland Ambulance Service reports also be included.

[Cactusjack]

Point number 4 is a good one - Culture.
Perhaps CASA's medical unit needs a NCN issued in response to its not utilising 'worlds best practise', plus it having a deficient culture? Then again CASA's overall culture with anything is pretty well crappy.
Poor Poopooshan, will the Screamer give him a smack on the Botty or a promotion?

[spinex]

The old adage; be careful what you wish for, comes to mind. In the a$$ covering fashion of bureaucracies worldwide, all that is likely to come of this is more pain for the average law abiding member of society, watch a medical become even more onerous and costly - the slightest deviation from an arbitrary standard will be referred to a specialist and so on ad nauseam.

No argument this disgraceful situation shouldn't have occurred, but I for one will not be holding my breath waiting for the guilty to be punished.

[Creampuff]

I agree with Spinex

Point number 4 is not a good one, Cactus.

CASA is already way too risk averse on the question of medical certificates.

Sorting out why Mr Hempel was issued a medical certificate, despite a medical history that would result in a refusal of a certificate for anyone else, is the appropriate response.

Denying lots of people medical certificates on the basis of remote risks is not the appropriate response.

[Frank Arouet]

A 'register' of unfit people, or a 'hit list' in the hands of CASA give me cause for concern. But then again I don't like the new centralized digital medical records either.

Of note also is the failure to recover the wreckage after The Coroner requested it be done so in a timely manner. That has some parallels with the Lord Howe Island matter.

The concept of a new engine and prop mitigating the conclusion that no mechanical failure is likely flies in the face of some US studies, (I can't remember where I read it), that put the most likely time for an engine failure as just after major overhaul.

I believe The Coroner got it right in general and one should include the word 'culture' in any dealings with our regulator. Any 'inter agency complexities' should also consider this.

[BPH63]

Look up your doctor here:

Australian Health Practitioner Regulation Agency - Registers of Practitioners

[Kharon]

John Hutton, Coroner.

The world is still deceived with ornament.
In law, what plea so tainted and corrupt,
But, being seasoned with a gracious voice,
Obscures the show of evil?

Cherry picked; (alas, with no hidden chanteys) but pertinent. Better men have lost much more, for much, much less. Now, was this all 'unfortunate' or:-

He had a contumelious disregard for aviation regulations and the law and he had an extensive history of offences and breaches. I attach hereto a schedule which is self-explanatory.

As shown by the Schedule of this decision, Mr Hempel had a long and extensive history, dating back to 1968, of breaching flying regulations.

His group of companies, including Hempel’s Aviation Pty Ltd, also had an extensive history of breaches of both administrative and flying regulations.

Given the above it goes without saying that he was well known by CASA and had had at one stage or other, inter alia, his Chief Flying Instructor delegation as an Approved Testing Officer ("ATO") withdrawn, his ATO delegations to issue aircraft endorsements removed and various other ATO delegations cancelled. Mr Hempel's licences, had, at various times, been suspended or cancelled.

"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."

The evidence at the Inquest gave an impression of a man who believed he was "above the law" so to speak.

It could be argued that the number and nature of Mr Hempel's breaches and the fact that many were repeated breaches indicated that Mr Hempel would probably never comply with safety regulations. In the light of the extensive history of breaches it is indeed extraordinary that he was left with even a Private Pilots Licence

What is truly perplexing about this case is that Mr Hempel had any kind of licence at all.

Given the litany of Barry Hempel’s breaches, one is left wondering why CASA allowed him to continue flying notwithstanding his ability to fly, but given his history of breaches, the question arises as to whether he was a fit and proper person to hold any kind of aircraft licence

Or; just plain (plane) protected ??.

No man is above the law and no man is below it; nor do we ask any man's permission when we ask him to obey it. (Theodore Roosevelt).

Avmed tomorrow, there are some questions methinks;.....

[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.

+++++++++++++++++++++++++++++++++++++++++++++++++++++


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...."

[halfmanhalfbiscuit]

This should be read alongside the recent senate inquiry with its 26 recommendations.

Interesting Atsb didn't investigate. Look at the two cases together might have told them something ?

[Kharon]

After all this time-

You have to admire the guile of Ian Harvey; you don't have to like it, but skill wherever or however manifested must be acknowledged. Clearly he understood the Coroner and neatly deflected the focus to matters medical, rather than matters related to why Hempel had for many years thumbed his nose at the authority. Starting at page 15 continuing to 16, is a neat little rant from Hutton, where his hobby horse is ridden around the arena. Harvey identified this, exploited it and probably had two bob each way on the result. Brava.....

No doubt the Coroner is well meaning and did not spare the Sleepy Hollow men; the now world infamous wet lettuce leaf lash was ferociously applied. Probably the only Coroner's recommendation, in the whole long history of ignored coronial recommendations will be the public flogging of pilots on a weekly list (register) assiduously provided by CASA to the industry. It is to be most sincerely hoped that this notion is stillborn. In the hands of the current crew it could, and (IMO) probably would be used as a lethal weapon.

Just say you came off the skate board one night, on your way home from the pub and some worthless FOI has it in for you. Now, your broken arm heals, just fine and the hangover has long since disappeared. You have been a good lad (or ladette) and reported the broken arm. Now you expect to be declared fit for duty; not so. You mate, are now down on an industry wide list, informing the world and it's wife that your broken wing is suspect and expected to fail during a safety sensitive period of flight; furthermore, that you need extensive close scrutiny while extensive testing for a suspected, deep seated, substance abuse problem is forensically examined. Privacy, forget about all that, your friendly FOI will simply cc the complaint to all and sundry. Couldn't happen you say, well: I'd have to disagree.

Hutton: "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"

Bollocks, I believe. Well intentioned, well meaning, but bollocks non the less. Long live the nanny state and the specialist care and feeding of protected species.

Selah.

[Frank Arouet]

I vigorously and urgently concur.

If any recommendations are adhered to, this will be it.