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Analysis

Summary

The circumstances of this accident were consistent with the pilot not being adequately prepared for an instrument approach in IMC. The pilot did not meet recency requirements for an NDB approach and was not qualified to make a GPS instrument approach. IFR pilots are required to consider their instrument flight currency before attempting flight in IMC. The amended Bankstown forecast obtained by the pilot at Warren should have alerted him to the possibility of an approach in IMC. The proximity of controlled airspace did not provide the pilot with the option of flying a cloud break procedure from a radar vector as intended. Subsequently, the pilot's decision not to divert when advised by the controller to expect an NDB approach led to the distraction from his normal flying duties and forgetting to select the main fuel tanks for the approach and landing.

The abrupt track change and subsequent excessive rate of descent at 17 NM from Sydney, as recorded by radar, was consistent with the pilot attempting to descend below the cloud base through a break in the cloud. Such a manoeuvre, below the minimum safe altitude, posed a significant risk of collision with obstructions or the ground.

The pilot's upper body restraint attachment failed due to an incorrect and weak installation. The investigation was unable to determine the circumstances of this installation but it was likely that it had remained undetected by maintenance personnel for a considerable period of time. The incorrect installation was not an obvious defect and maintenance personnel had no means of readily referencing the relevant installation information for comparison.

 
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