Also observed doing a roll on downwind a few weeks prior. I wonder what sort of aerobatic endorsement he held - spinning and aerobatic endorsements 5 months prior indicates Aerobatics - 3,000 ft AGL?

Report out. https://www.atsb.gov.au/media/578077...-027-final.pdf

Some of the speculation earlier in this thread proved correct I think.

So 3 years to compile a report which says we don't know what happened. We found something that might have caused it, but we sent out a memo about that 2 years ago, so job done. Next!

Honestly, why do we bother with all this palaver for an accident that killed two people? Tragic that it is, if the same two people had died in a car accident on the way to the aerodrome before the flight because perhaps one of them was doing something that he probably should not have been doing, like perhaps speeding, but we can't confirm it, it would have made the news for a day and be long forgotten.

With respect, every death on the road is fully investigated. It may make the news for a 45 second bite but the investigation will be done and findings made. The difference, it won't take 3 years.

40hrs on type.
Case closed.
Next.

I know the police do an investigation, which seems to be a prerequisite for the resulting coronial investigation, and that seems to be as far as it goes. Like you say, it doesn't take three years and try and reinvent the wheel.

Sorry but a quick search of coronial inquests results in Victoria and the first one took 4 years to deliver being complicated, the next 5 between 2 years to 6 months depending on complexities. Quite simply, no one witnessed the crash, there was no hard evidence of causality only speculative evidence. In these cases the investigation will hold out for any chance of further evidence that could change the outcome and then release.

Comparing to road investigations is unfair. In most road collisions there will be lots of witnesses, cameras, skid marks and fairly straight forward analyses can be done fast and efficiently. With air incidents, especially this one there is lots of speculative evidence based on past habits, however no hard evidence of cause can be ascertained. You can only rule out what did not happen and then report on the most probable occurrence. The only hard evidence, the aircraft crashed at high speed, it was not survivable, the pilot was healthy enough to rule out incapacitation and RADAR plots were indicative of erratic flight path. The rest is speculative as to what was occurring and why. With such limited evidence, put the file on the shelf and wait for any chance of additional evidence such as a reluctant witness, some lucky video capture from the edge of frame, some go-pro or similar that washes up from the crash, etc etc....

Here’s the Coroner’s report;

Report

I wonder if some changes are coming after what has been recommended in there…. It’s quite a read.

Interesting to read the (expensive) extent of CASA’s largely unsuccessful attempts to focus blame on a single individual and away from the systemic regulatory issues.

Almost 4 years and the finding;

So as said above they knew most of what happened a few days/weeks in and then waited for any extra information to come to light, after time has passed and nothing comes of it, then publish what you do know.

That being said recommendations to CASA are many and noteworthy and hopefully have some follow through.

This is another example of CASA acting in a reactive manner rather than a proactive one. I think trying to take Mr Field to the cleaners is both unfair & unwarranted, when the real issues lay within the nebulous CASA systems within which pilots have to navigate. Without wanting to speak badly of the deceased, it appears clear to me from the material presented at the coronial hearing, that Mr Van Hattem was a cowboy & unfortunately, has taken a young life with him...

I wonder if Dr Stanton is CASA's subject matter expert for aerobatic training? I know that he has some experience at this and was highly regarded.

"132. Mr Awad, the former CEO of AWAL (from 2013 – 2021) gave evidence that his aerobatic endorsement in the USA took in the order of 10 hours. He undertook a series of training flights with a check pilot who was a very experienced aerobatic pilot with each flight being “roughly between one and 1.5 hours in duration”. He considered eight to ten hours to be “the basic”.
133. CASA’s Branch Manager of Sport and Recreation Aviation, Dr Anthony Stanton, gave evidence that he would expect a flight activity endorsement to take eight hours, and “on average 10 to 15 hours”. In his experience, the instruction should take place with a series of lessons. .....
134. Dr Stanton said that if a student seemed to have had some prior aerobatics training that would not justify a truncation or shortening of the instruction time. He added:
If he came to me, I would actually take longer ..."
Mr Awad could not have got an aerobatic endorsement in the USA because the FAA does not have such an endorsement. So, Dr Stanton would expect Mr Awad to undergo 10-15+ hours of training in Australia on top of his 10 hours in the USA to get a CASA aerobatic endorsement?

'Dr Stanton was specifically asked the following: Is it something that CASA can look into as to whether flying schools - have an adequate knowledge - if I can put it that way - of what they are meant to be doing in terms of (a) developing their syllabus and (b) ensuring that if the spin recovery methods are to be the methods prescribed in a pilot operating handbook or flight manual, that those are the methods only to be used? ---CASA recently did publish a spinning AC. I'm reasonably confident that that content is contained in that AC, but I certainly have a review of it to make sure it is, but I’d be surprised if that’s not in there." Not true, Dr Stanton, there is no AC on spinning and you have withdrawn CAAP 155-1, Aerobatics, with no sign of a replacement AC on aerobatics & spinning!

""210. ... CASA takes issue as to the terminology used (“flight training operators or organizations” and “flight instructors”), submitting that it is neither necessary nor appropriate to review flight instructor standards of performance and consequentially, the recommendation should not be accepted."
What about the requirement for spin and aerobatic instructors in CASA 62/20 — Conditions on Flight Crew Authorisations (Edition 3) Instrument 2020..

A question that comes to mind to me is the Counsel Assisting the Coroner in this matter - Ian Harvey, was CASA's lawyer for coronial inquiries & other matters for some time, so is there a conflict of interest issue relevant here? I'm not sure how long ago he last represented CASA, but I'm wondering if CASA may have been let off the hook to some degree due to this previous relationship.