Aviation safety investigations & reports

VFR into IMC, Kawasaki Heavy Industries BK 117 B-2 helicopter, VH-BKS, 76 kms north of Brisbane Airport, Qld

Investigation number:
Status: Completed
Investigation completed


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On 11 October 2005 at about 1815 Eastern Standard Time, a Kawasaki Heavy Industries BK 117 B-2 helicopter, registered VH-BKS, became airborne at Brisbane's Princess Alexandra Hospital on a night Visual Flight Rules (VFR) flight to Maroochydore, Qld. On board the helicopter were the pilot, a paramedic and a crewman. The pilot had earlier departed Hervey Bay on a day VFR medical flight, arriving at the hospital at 1748 that afternoon. The incident flight was to reposition the helicopter at the operator's Maroochydore base location.

At about 1823, the pilot was advised by the Brisbane Approach North controller that the weather at Maroochydore included broken cloud, with a cloud base of 1,000 ft above ground level (AGL). In addition, the pilot reported that he observed a solid layer of cloud beneath and in front of the helicopter along the intended route.

The pilot's decision to continue the flight to Maroochydore committed the pilot to a night VFR flight above more than scattered cloud. The pilot could not assure himself of maintaining Visual Meteorological Conditions (VMC) during the remainder of the flight, with the result that the night VFR flight above more than scattered cloud was not possible.

On arrival at Maroochydore, the cloud base was such that the pilot was restricted to a recovery to land via an instrument approach, in conditions in which he was not qualified to operate, and for which the helicopter was not single-pilot instrument flight rules-equipped.

The report also details extensive safety action undertaken by the operator, the Queensland Department of Emergency Services, Airservices Australia and the Civil Aviation Safety Authority.

Download Final Report
[Download  PDF: 789KB]

Interim Factual

Interim Factual report released 22 November 2005

At 1828 Eastern Standard Time on 11 October 2005, a Kawasaki Heavy Industries BK117 B-2 multi-engine helicopter, registered VH-BKS, was being operated on a night Visual Flight Rules (VFR) flight to Maroochydore, Qld. The pilot, had flown the helicopter on a medical flight from Maroochydore to Brisbane's Princess Alexandria Hospital earlier that evening and was repositioning to Maroochydore with the paramedic and crewman on board.

The pilot intended to fly direct to Maroochydore, VFR on top of scattered1 cloud at 4,500 ft. Soon after reaching 4,000 ft, the pilot noted that the cloud along the intended track was 4 OKTAS below the level of the helicopter. However, shortly after, the pilot observed the weather as solid overcast beneath him. He reported that the Brisbane approach controller subsequently advised him that the weather at Maroochydore had deteriorated to broken cloud at 1,000 ft above ground level (AGL).

The pilot continued with the flight to Maroochydore and conducted a Maroochydore runway 36 VOR/DME2 approach in Instrument Meteorological Conditions (IMC). The helicopter was not equipped for single-pilot Instrument Flight Rules (IFR) operations, nor was the pilot the holder of a current Command Multi- Engine Instrument Rating (Helicopters).

The pilot reported that he did not return to Brisbane because the Brisbane Approach controller made a broadcast to all aircraft inbound to Brisbane 'that an Instrument Landing System (ILS) approach was mandatory'. He said that he assumed this to mean he would have to conduct an IFR approach he was unfamiliar with. He did not declare an emergency. The pilot was an experienced ex-military pilot, with extensive IFR experience. He reported entering cloud at 2,600 ft and broke visual during the approach at 760 ft. The IFR minimum descent altitude for that approach was 660 ft. The pilot reported landing with 45 minutes usable fuel remaining.

Area forecasts indicated that, for the planned flight, VFR operations were possible. The pilot planned the flight using a TAF (Terminal Aerodrome Forecast) for Maroochydore that was valid from midday to midnight on the day of the occurrence. That TAF indicated visibility greater than 10 km and scattered cloud at 2,500ft. The pilot assessed this as suitable for VFR.

An amended TAF for Maroochydore valid from 1800 that evening through to 0600 the following morning, was issued by the Bureau of Meteorology at 1626. That TAF indicated visibility greater than 10 km, few3 clouds at 1,000 ft and scattered cloud at 2,500 ft. The pilot reported he did not have the amended TAF and did not access further weather information after 1400 because he had assessed, during the preceding flight to Brisbane, that the weather was suitable for a return VFR flight to Maroochydore.

  1. Defined as 3 to 4 OKTAS (unit of visible sky area representing 1/8 of the total area visible to the celestial horizon).
  2. VHF Omni-directional radio range/Distance Measuring Equipment.
  3. Defined as 1 to 2 OKTAS.
General details
Date: 11 October 2005   Investigation status: Completed  
Time: 1828 EST    
Location: 46 km N Brisbane Airport    
State: Queensland   Occurrence type: VFR into IMC  
Release date: 29 June 2007   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Kawasaki Heavy Industries  
Aircraft model BK117  
Aircraft registration VH-BKS  
Serial number 27945  
Type of operation Aerial Work  
Damage to aircraft Nil  
Departure point Princess Alexandra Hospital, Qld  
Departure time 1814  
Destination Maroochydore, Qld  
Last update 16 February 2016