Coronial
QLDother

Hempel, Barry Ian; Lovell, Ian Ross

Deceased

Barry Ian Hempel and Ian Ross Lovell

Demographics

male

Coroner

Hutton

Date of death

2008-08-31

Finding date

2013-10-04

Cause of death

Multiple injuries from aircraft crash; underlying cause - epileptic seizure suffered by pilot during flight resulting in loss of aircraft control

AI-generated summary

Two men died when a Yak-52 aircraft piloted by Barry Hempel crashed into the Pacific Ocean. Evidence suggests Hempel suffered an epileptic seizure mid-flight, rendering him incapacitated and unable to control the aircraft. The passenger's urgent radio transmission ('Oh my god, what are you doing?') and Hempel's failure to respond support this. Hempel had a 2001 head injury causing brain scarring that predisposed him to seizures. He had multiple subsequent seizure episodes (2002) documented by ambulance paramedics and prescribed Tegretol (an anti-epilepsy drug) by his GP. Despite receiving the ambulance reports, CASA failed to act decisively. His GP (Dr S.) did not communicate concerns about epilepsy to the assessing neurologist (Dr M.), who therefore recommended licence restoration. Hempel held only a Private Pilot's Licence but illegally conducted fee-paying joy flights. Systemic failures included: CASA's failure to properly investigate medical alerts; lack of information sharing between medical practitioners; absence of mandatory medical reporting for epilepsy; and failure to retrieve and examine the crashed aircraft. The coroner emphasised that proper investigation of seizure reports by CASA and communication between healthcare providers could have prevented this tragedy.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

neurologyaviation medicineemergency medicinepathologygeneral practice

Error types

diagnosticcommunicationsystemdelay

Drugs involved

carbamazepine

Clinical conditions

epilepsypost-traumatic seizure disorderhead injury with brain contusion and scarringtonic-clonic seizure

Contributing factors

  • Pilot's undiagnosed/unmanaged epilepsy following 2001 head injury
  • CASA's failure to investigate ambulance reports of seizures dated 1 July 2002 and 29 October 2002
  • Failure of GP (Dr S.) to communicate epilepsy concerns and Tegretol prescription to assessing neurologist
  • Pilot's deception regarding medical history when assessed by neurologist
  • Lack of mandatory medical reporting system for epilepsy to aviation authorities
  • CASA's acceptance of pilot's assertions without independent verification
  • Absence of public register of suspended/cancelled pilot licences
  • Poor medical record-keeping by GP
  • Pilot operating with only Private Pilot's Licence while conducting fee-paying flights
  • Pilot's extensive history of regulatory breaches and disregard for safety regulations

Coroner's recommendations

  1. CASA should immediately disseminate names of pilots who have had conditions imposed, suspension or cancellation of licence by email to industry
  2. CASA should immediately introduce a Register of Pilots including licence suspensions and cancellations, made readily available on CASA website, briefing newsletter, and Flight Safety Australia magazine
  3. Public awareness campaign about the existence of the Pilots Register to alert all pilots, airports and aviation industry members
  4. When investigating pilot medical fitness, CASA should obtain ambulance/paramedic reports and hospital reports upon notification of ambulance attendance and speak to report authors
  5. CASA should forward relevant ambulance/paramedic and hospital reports to the pilot's Aviation Medical Examiner
  6. CASA should review the 'culture' within its Medical Unit to move away from accepting medical information provided by pilots toward a more cautious approach, particularly for pilots at risk of losing licence
  7. Queensland government should consider participating in the Commonwealth centralised medical treatment system (eHealth) and consider including Queensland Ambulance Service reports in such system
Full text
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