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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.


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.



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