Australia's aviation watchdog has come under fire after it transpired that a pilot who killed himself and a British passenger in a crash during a sightseeing trip in Queensland should not have been flying.
Ian Lovell died in 2008 during a 'joy flight' over Moreton Bay in Queensland, which his girlfriend Samantha Hare had bought as a gift for his 35th birthday.
It is believed the 60-year-old pilot, Barry Hempel, suffered an epileptic fit during the flight, crashing the plane into the Pacific Ocean.
Mr Lovell had been in Australia for four years, following his dream of combining travel with his work as a computer game animator.
Queensland coroner John Hutton has now found the Civil Aviation Safety Authority (CASA) knew Mr Hempel had a history of seizures and safety breaches, but did not ground him.
According to ninemsn, repeated aviation breaches had seen the pilot stripped of his licence to carry paying passengers.
But CASA did nothing to revoke his private pilot's licence, and Ms Hare was unaware of the pilot's history of breaches and seizures when she booked the flight.
The Australian reports that Mr Hutton said it was "unbelievable" that CASA allowed the pilot to keep his private licence.
He added: "It is unbelievable that CASA did not act."
According to the Express and Star, he added: "It is also unbelievable that when Dr (Ian) Maxwell was briefed to assess Barry Hempel, a copy of this report was never provided to him, nor was he advised as to the admissions as to two previous seizures."
Instead, the neurologist had to rely on Mr Hempel to disclose his medical history.
"During the inquest it became obvious that CASA medical officers were cavalier in respect to the QAS reports and CASA medical officers chose to disregard the observations of trained paramedics", added Mr Hutton.
Mr Hutton recommended that CASA begin releasing the names of pilots whose licences are cancelled or changed, and set up a register to record pilots' licence details.
Mr Lovell's family and Ms Hare have campaigned throughout the five years since his death for an investigation into why Hempel was allowed to fly.
His mother Lynn said the coroner's report had brought closure after five years, and she wanted to see his recommendation for a mandatory register of pilots brought in as soon as possible.
She told the Express and Star: "Hempel had no regard for anybody. He was a maverick, a cowboy and a liar, everything you wouldn't want to know in a person.
"Now they have to be seen to be doing something. Something has got to happen, this can't happen to another family."
US plane crash blamed on drunk pilot
Horror at Madrid air show as plane crashes and explodes