CASA cancels AGAIR’s AOC after fatal Cloncurry crash

It follows the crash of a Rockwell 695A Jetprop Commander, VH-HPY, near Cloncurry in Queensland on 4 November 2023, which the ATSB later concluded was likely due to pilot hypoxia from a faulty pressurisation system of which AGAIR had been aware for some time.

Three people were killed, including the pilot and two camera operators, after the pilot lost control of the plane at around 10,500 feet and crashed into the ground.

“The authorisation holder was on notice of pressurisation maintenance defect issues, but continued to allow the aircraft to fly missions at altitudes where it was clear that the defective pressurisation system of the aircraft was a serious safety issue,” said CASA.

“The authorisation holder oversaw a culture of systemic failure to record defects and allowed aircraft to continue to fly with non-permissible defects that should have grounded the aircraft. This inculcated a poor safety culture within the company and compromised aviation safety.”

The regulator also noted “various instances of pilots not recording aircraft defects on the maintenance release, pilots operating aircraft with scheduled maintenance tasks on the MR overdue, pilots operating aircraft with non-permissible defects recorded on the MR and pilots carrying out non-permitted aircraft maintenance”.

In its report into the crash last year, the ATSB found that AGAIR’S internal correspondence and maintenance documents showed the aircraft suffered from a “long‑term intermittent defect with the pressurisation system”.

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“This was a tragic and entirely unnecessary accident that underscores the dangers of operational practices which circumvent critical safety defences, and the insidious and deadly potential of altitude hypoxia,” said ATSB chief commissioner Angus Mitchell.

“Over a period of many months, the accident aircraft’s pressurisation system was not reliably maintaining the required cabin altitude.

“This led some company pilots to employ a variety of actions in the aircraft to manage the potential and deadly effects of hypoxia, including at times briefly descending to lower altitudes, and improperly using emergency oxygen systems.”

AGAIR management knew of the defect, added Mitchell, and “attempted to have it rectified”.

“However, they did not formally record the defect, communicate it to the safety manager, undertake a formal risk assessment of it, or provide explicit procedures to pilots for managing it,” he said.

“Instead, AGAIR management personnel participated in and encouraged the practice of continuing operations in the aircraft at a cabin altitude of 19,000 ft, and as such required the use of oxygen, without access to a suitable oxygen supply.”

The pilot had also “normalised the practice of managing the intermittent pressurisation issue by undertaking short descents to lower altitudes, and by using the aircraft’s emergency oxygen system”, according to correspondence and flight data examined by the ATSB.

“This represented a practice of using a critical safety system designed for emergency use only, in order to continue a commercial activity,” said Mitchell.

According to the ABC, AGAIR has lodged stay applications against the cancellations, with a phone hearing scheduled in the Administrative Review Tribunal later this month.