Scholl, Philip Henry

Contributing factors

• aircraft not airworthy - degraded wing fabric, corroded and frayed cables, failed luff lines
• inadequate pilot training - only 20 hours flight time, limited theory instruction
• inadequate aircraft inspection - aircraft condition statement incomplete and inappropriate, 'do not start' placard ignored
• aircraft unregistered with HGFA from 20 June 2005 to 13 October 2005
• lack of formal search and rescue procedures at facility
• delayed emergency response - alarm not raised until 5pm despite 2-hour flight plan
• regulatory gaps in recreation aviation oversight by CASA
• instructor failed to establish clear flight plans and safety procedures
• aircraft maintenance records inadequate and incomplete
• level two maintenance authority issued inappropriate inspection report

Coroner's recommendations

1. CASA should endorse only one delegate to regulate weightshift aviation
2. CASA should initiate regular compliance audits for all levels of recreation aviation industry
3. CASA should empower RAAO's to suspend and cancel certificates/licences
4. CASA should review operations and funding arrangements of all RAAO's
5. CASA should investigate trial instruction flights to determine if commercially operated
6. CASA should review operation of RA-AUS and HGFA to standardise procedures
7. CASA should investigate and prosecute regulatory breaches
8. CASA should conduct review of persons authorised to complete UCAR assessments
9. CASA should review suitability of AirBorne Edge aircraft for registration
10. CASA and RAAO's should compare policies with British Microlight Aircraft Association and adopt superior policies
11. CASA and RAAO's should implement mandatory aircraft flight log books
12. CASA and RAAO's should require detailed flight plans left at facilities
13. CASA and RAAO's should ensure standard operating procedures at all facilities
14. CASA and RAAO's should develop standard generic operating procedures code of practice
15. CASA and RAAO's should conduct hazard identification audits at all facilities
16. CASA and RAAO's should review pilot licensing to introduce restricted licensing levels
17. CASA and RAAO's should review shortcomings in training, maintenance, transfer procedures, inspection
18. CASA and RAAO's should require mandatory independent aircraft condition reports for transfers
19. CASA and RAAO's should eradicate culture of minimal compliance and promote air safety priority
20. CASA and RAAO's should develop common policies if multiple delegated authorities continue
21. CASA and RAAO's should develop enforcement policies preventing avoidance through resignation
22. CASA and RAAO's should develop inter-organisational cooperation culture
23. ATSB should investigate all aircraft crashes resulting in death
24. WHSQ should review commitment to regulation of recreation aviation
25. WHSQ should review procedures for registration of aircraft and airfields as workplaces
26. Recommend CASA and ATSB become more involved in operation of ultralight aircraft
27. CASA should ensure periodic training updates sent to maintenance authorities
28. CASA and RAAO's should ensure tumbling hazard is part of pilot training
29. CASA and RAAO's should develop module alerting pilots to airworthiness issues
30. CASA and RAAO's should develop systems ensuring competency in flight operation and emergency response
31. Recreation aviation industry should implement single standard training syllabus
32. Pilot licences should be issued after practical assessment by independent endorsed person
33. All aircraft crash investigators should receive standardised training
34. CASA should implement maintenance release forms as used in general aviation
35. CASA and RAAO's should implement mandatory recorded annual Bettsometer tests
36. CASA and RAAO's should review aircraft maintenance record requirements and develop code of practice
37. CASA and RAAO's should review competency of Level One maintenance authorities
38. Aircraft manufacturers should include Bettsometer as essential tool at point of sale
39. Aircraft manuals should refer to Bettsometer use and publish condemning weight
40. Maintenance schedules should have sequential numbering and date of performance
41. Maintenance authorities should interrogate maintenance logs when preparing condition reports
42. Aircraft log books should ensure sufficient recording for honest history
43. Aircraft log books should allow provision for additional notations
44. Level Two authorities should adhere strictly to manufacturer schedules or RA-AUS manual
45. Aircraft condition reports should be completed only by competent persons assessed biannually
46. All microlight aircraft should undergo mandatory biennial inspection by independent Level Two authority
47. CASA should review endorsement of aircraft types where tumbling events found
48. CASA should require VHF radios mandatory in all aircraft with emergency frequency placard
49. CASA should require EPIRB device with GPS positioning mandatory in aircraft
50. CASA and RAAO's should inform all owners and pilots of microlight tumbling risk
51. Wing manufacturers should research and develop tumble resistant wings
52. CASA and RAAO's should ensure safety and health management plans at all facilities
53. CASA and RAAO's should develop standard generic safety management plan code of practice
54. Level Two maintenance authorities should be given clear authority to ground aircraft
55. CASA and ATSB should investigate all known AirBorne Edge crashes for engineering or design faults
56. CASA and RAAO's should ensure emergency response plans at all facilities understood and implemented
57. CASA should develop standard generic emergency response plan code of practice
58. Incident sites should be treated as crime scenes, isolated and guarded to protect evidence