The ATSB's final investigation report into a Piper Chieftain
accident near Condobolin, NSW on 2 December 2005, resulting in four
deceased persons, confirms that the aircraft broke up during flight
when its structural limits were exceeded in the vicinity of
thunderstorms.
The Australian Transport Safety Bureau report states that there
was no indication, either by way of emergency radio transmission
from the pilot, or in a change in the altitude, track and speed of
the aircraft as recorded by radar, that the flight was not
proceeding normally. Some minutes after the pilot reported
diverting left of track to avoid weather, communications with the
aircraft were lost.
The absence of an on-board recording device on the aircraft
prevented a full analysis of the circumstances of the breakup.
However, while post-impact fire damage limited the extent to which
some of the aircraft's system's, including the fuel and electrical
systems, could be examined, wreckage examination did not reveal any
pre-existing fault or condition that could have weakened the
aircraft structure and caused it to break up at a load within the
design load limit.
A line of severe thunderstorms crossed the aircraft's planned
track and were the subject of a SIGMET (significant weather advice)
issued by the Bureau of Meteorology. As the SIGMET information did
not meet the criteria for direct notification, it was not advised
directly to the pilot of the aircraft. The investigation was unable
to determine if the pilot had obtained the SIGMET from any of the
range of pre and in-flight weather briefing services available to
the pilot.
Analysis of the prevailing weather indicated that, immediately
before the accident, the aircraft was likely to have been
surrounded to the east, west, and south by a large complex of
thunderstorms. That situation may have limited the options
available to the pilot to avoid any possible hazardous phenomena
associated with the storms.
Although, as a result of a review of Flight Information Service
initiated in November 2004, Airservices Australia had identified
inconsistencies and ambiguities in the provision of Flight
Information Service, including Hazard Alert procedures, they were
not assessed by the investigation to be contributing factors to the
accident. As a result of its review, Airservices Australia
initiated changes to the Flight Information Service and Hazard
Alerts sections of the Manual of Air Traffic Services and
the Aeronautical Information Publication to improve future
safety.
While not contributory to the accident, the report identifies a
number of inconsistencies between Australian SIGMET issemination
procedures and those contained in International Civil Aviation
Organization (ICAO) documentation. The report contains
recommendations to Airservices Australia and the Civil Aviation
Safety Authority to review Australian procedures with a view to
minimising those inconsistencies.
The circumstances of the accident are a salient reminder to
pilots of their responsibilities to request weather and other
formation necessary to make safe and timely operational decisions,
and of the importance of avoiding thunderstorms by large
margins.
Copies of the report can be downloaded from the ATSB's internet
site at
www.atsb.gov.au.
Media Contact: 1800 020 616