The investigation into the collision with water off Horn Island, Queensland (AO-2011-033) highlights the importance of pilots having enough sleep before a flight and for operators to manage potential fatigue risks.
On 24 February 2011 the pilot of an Aero Commander 500S commenced a freight charter flight from Cairns to Horn Island at 0445 Eastern Standard Time under the instrument flight rules. The aircraft arrived at Horn Island at about 0720 and the pilot advised air traffic control that he intended holding east of the island due to low cloud and rain. At 0750 he advised that he was north of Horn Island and intending to commence a visual approach. When the aircraft did not arrive a search was commenced but the aircraft was not found. It was eventually located on about 10 October 2011 on the seabed about 26 km north‑north‑west of the island.
The ATSB investigation found that the aircraft had not broken up in flight and that it had impacted the water at relatively low speed and a near wings-level attitude, consistent with it being under control at impact. There is insufficient evidence to determine why the aircraft impacted the water, however, several aspects of the flight increased risk. The pilot had only 4 hours sleep the night before the flight and the operator did not have any procedures or guidance in place to minimise the fatigue risks of early starts. In addition, the pilot, who was also the operator’s chief pilot had either not met the recency requirements or did not have an endorsement to conduct the types of instrument approaches available at Horn Island and other locations.
The operator ceased operations following the accident and therefore did not have the opportunity to improve its processes. CASA has issued a notice of proposed rule-making relating to flight crew fatigue management. In the case of single pilot public transport operations, this included a proposal to limit the duration of a flight duty period and the number of late night flight duty periods in certain circumstances.Last update 04 January 2013