Aviation safety investigations & reports

Midair collision – Cessna Aircraft A150M, VH-UPY and Piper Aircraft PA-28-161, VH-CGT, 3 km NW of Moorabbin Airport, Vic, 27 August 2008

Investigation number:
AO-2008-059
Status: Completed
Investigation completed

Summary

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On 27 August 2008 at 1238 Eastern Standard Time, a solo student pilot in a Cessna Aircraft Company A150M aircraft, registered VH-UPY (UPY), and a student pilot and instructor in a Piper Aircraft Corp PA-28-161 aircraft, registered VH-CGT (CGT), were flying about 3 km north-west of Moorabbin Aerodrome, Victoria.

The pilot of UPY conducted a touch-and-go on runway 31 left (31L) at Moorabbin as CGT was entering the control zone from the north-west at 1,000 ft above mean sea level (AMSL) to join the circuit on left downwind for runway 31L. As CGT approached the circuit pattern, the student pilot saw UPY, very close and climbing from his left on a collision course, and took avoiding action. However, the two aircraft collided, resulting in UPY colliding with terrain and fatal injuries to the solo student pilot.

In the time leading up to the collision, the air traffic controller workload had been high and relevant traffic information was not issued to the pilots in sufficient time to assist self‑separation. The investigation identified that the design of the then Moorabbin Aerodrome General Aviation Aerodrome Procedures (GAAP) airspace did not provide lateral or vertical separation between traffic flows, and that this increased the risk of a midair collision. In addition, Airservices Australia (Airservices) had not acted on a number of internal recommendations to manage a gradual increase in operations at Moorabbin.

As a result of this investigation, Airservices have undertaken a review of their internal processes for reviewing safety performance. In addition, as a result of a number of midair collisions in the vicinity of GAAP aerodromes, the Civil Aviation Safety Authority (CASA) undertook several reviews of GAAP leading to improved training procedures and, as an interim measure, restrictions on the number of aircraft in the circuit. On 3 June 2010, CASA implemented Class D airspace procedures at all GAAP aerodromes throughout Australia.

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Preliminary

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Preliminary Report Released 22 October 2008

On 27 August 2008 at 1238 Eastern Standard Time, a Cessna Aircraft Company A150M and a Piper PA-28-161 collided 3 km north-west of Moorabbin Airport, Vic. The Cessna impacted the ground following the collision and fatally injured the student pilot. The instructor in the PA-28 was able to land the aircraft at Moorabbin Airport without any further damage.

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Inquest

VH-UPY/VH-CGT response to the Coroner

The ATSB notes that the Victorian State Coroner, Judge Ian L Gray has recently released findings and, subsequently, amended findings  into the death of the pilot of VH-UPY without holding an inquest. The Coroner’s findings largely adopt the findings made by the ATSB in its report published on 31 May 2011.

Circumstances of the accident

The pilot of VH-UPY conducted a touch-and-go on runway 31 left (31L) at Moorabbin as VH-CGT was entering the control zone from the north-west. As VH-CGT approached the circuit pattern, the pilot of VH-CGT saw VH-UPY, very close and climbing from his left on a collision course, and took avoiding action. However, the two aircraft collided, resulting in VH-UPY colliding with terrain and fatal injuries to its pilot.

ATSB Findings

In terms of Contributory Safety Factors the ATSB found that the occupants of VH-UPY and VH-CGT did not see each other in time to prevent the collision. Further, relevant traffic information was not provided to either aircraft by the aerodrome controller who had been operating in a high workload environment in the period leading up to the midair collision which increased the risk of information not being able to be provided to flight crews. The ATSB also found that the risk of midair collision was increased by the Moorabbin Aerodrome General Aviation Aerodrome Procedures airspace design that did not assure lateral or vertical separation.

Other safety factors

Before the collision, the provision of relevant traffic information to pilots was sometimes incorrect or late. There was no evidence of any action taken by Airservices Australia to address safety recommendations related to a review of key performance indicators of General Aviation Aerodrome Procedure airspace operations. The student pilot of VH-UPY had not yet demonstrated an ability to operate safely in a busy circuit environment and his flight instructor did not provide any guidance to the student in the situation where the circuit activity changed during the solo flight. The ATSB determined, however, that the evidence did not demonstrate that the lack of supervision contributed to the development of the accident. The Coroner accepted that finding and while he considered that the lack of supervision may have been a contributing factor noted that the degree of contribution was indeterminate. The ATSB notes that for a matter to be a contributory safety factor for the purpose of ATSB investigations there must be a probability of at least 67 per cent. 

The Coroner noted, however, that corrective actions had rectified deficiencies in the supervision of student and supervising pilots and reduced the risk of future events.

Other key findings

There was no indication of any communication difficulties that could be attributed to the use and comprehension of English by the pilots or controllers involved. There was no indication of any significant factor in either student’s training that may have increased the likelihood of a midair collision.

Submissions

The ATSB made submissions to assist the coronial investigation. The Coroner was satisfied that the circumstances of the accident were thoroughly investigated and considered by the ATSB. The Coroner also noted that the ATSB had conducted a thorough review of all Loss of Separation Incidents for the period January 2008 to June 2012 resulting in observations, recommendations and safety messages.

ATSB investigations and coronial investigations

Coronial investigations are separate to ATSB investigations. In this matter the respective authorities are largely in accord as to the factors that contributed to the development of the accident.

The ATSB's report can be downloaded by clicking on the link:  ATSB Report

The Coroner's report can be obtained from the Coroner's Court of Victoria. Contact details are available at: www.coronerscourt.vic.gov.au/home. Queries regarding the Coroner's findings should be directed to the Coroner's Court of Victoria.

 

 

Safety Issues

Go to AO-2008-059-SI-01 - Go to AO-2008-059-SI-02 -

Airspace design for strategic separation

Moorabbin GAAP airspace design did not assure lateral or vertical strategic separation between traffic flows. This increased the risk of a mid-air collision.

Safety issue details
Issue number: AO-2008-059-SI-01
Who it affects: Pilots flying in D airspace at a capital city general aviation airport
Status: Adequately addressed

Action related to review of GAAP operations

There was no evidence of any action taken by Airservices to address safety recommendations related to a review of Key Performance Indicators (KPI’s) of GAAP operations.

Safety issue details
Issue number: AO-2008-059-SI-02
Who it affects: Pilots flying in D airspace at a capital city general aviation airport
General details
Date: 27 August 2008   Investigation status: Completed  
Time: 1235 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Near Moorabbin Airport    
State: Victoria   Occurrence type: Airborne collision  
Release date: 31 May 2011   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 150  
Aircraft registration VH-UPY  
Serial number A1500653  
Type of operation Flying Training  
Damage to aircraft Substantial  
Departure point Moorabbin Vic.  
Destination Moorabbin Vic.  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-28  
Aircraft registration VH-CGT  
Serial number 28-7816223  
Type of operation Flying Training  
Damage to aircraft Substantial  
Departure point Moorabbin, Vic.  
Destination Moorabbin, Vic.  
Last update 14 November 2018