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At about 1452 Eastern Daylight-saving Time on 24 December 2008, a Cessna Aircraft Company 172L aircraft, registered VH-EKS, with a pilot and one passenger, departed Mudgee on a private visual flight rules (VFR) flight to a property near Glen Innes, New South Wales. About 15 minutes after departure, the pilot encountered increasing cloud and, after climbing to assess the weather ahead, decided to descend visually through the cloud in order to maintain visual meteorological conditions.

The pilot descended the aircraft into a valley that was enshrouded in cloud. After flying up the valley for a short time, the pilot decided to turn back. During the turn-back manoeuvre, the aircraft entered cloud. The pilot became disorientated and the aircraft collided with terrain.

The pilot and passenger were seriously injured and the aircraft was seriously damaged. Shortly after, the passenger succumbed to his injuries.

The pilot's decision not to obtain the relevant Bureau of Meteorology forecasts prevented a full understanding of the weather likely to affect the flight and what impact this might have on his flight planning, including alternate routes and fuel requirements. Similarly, the pilot's decision not to submit any form of formal flight notification, and to not replace the normally-carried portable Emergency Locator Transmitter, adversely affected the prompt commencement of a search and rescue following the accident.

While not contributory to the accident, the investigation identified an error in the flight planning requirements in the Visual Flight Guide (VFG) for VFR flights away from a departure aerodrome. The Civil Aviation Safety Authority (CASA) has advised that the VFG has been withdrawn for amendment.

The investigation also identified that the optional nature of the navigational component of the Aeroplane Flight Review (AFR) meant that a pilot's navigation skills could remain un-assessed for an extended period. While this did not contribute to the accident, CASA has advised that the optional nature of the navigational component will be amended to being a recommended element of the AFR, and that guidance will be provided on its conduct.

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ATSB response to the Coroner

The ATSB notes that NSW Deputy State Coroner, Sharon Freund has recently released a finding into a fatal accident involving aircraft registered VH-EKS.  The ATSB was not required to give evidence, however the report of the ATSB was utilized by the Coroner for the purpose of her findings.  The Coroner’s findings were substantially in accordance with the ATSB investigation.

Circumstances of the accident

At about 1452 Eastern Daylight-saving Time on 24 December 2008, a Cessna Aircraft Company 172L aircraft, registered VH-EKS, with a pilot and one passenger, departed Mudgee on a private visual flight rules (VFR) flight to a property near Glen Innes, New South Wales. About 15 minutes after departure, the pilot encountered increasing cloud and, after climbing to assess the weather ahead, decided to descend visually through the cloud in order to maintain visual meteorological conditions.

The pilot descended the aircraft into a valley that was enshrouded in cloud. After flying up the valley for a short time, the pilot decided to turn back. During the turn-back manoeuvre, the aircraft entered cloud. The pilot became disorientated and the aircraft collided with terrain.

The pilot and passenger were seriously injured and the aircraft was seriously damaged. Shortly after, the passenger succumbed to his injuries.

ATSB Findings

The ATSB made the following findings:

Contributing safety factors

  • The pilot chose not to obtain the relevant aviation weather forecasts for the flight.
  • The pilot chose not to turn back or divert, after climbing to 7,500ft and identifying deteriorating weather ahead.
  • The weather conditions were such that there was an increased risk of the pilot being unable to continue the flight in visual meteorological conditions.
  • The pilot flew into instrument meteorological conditions, in which he was not qualified to operate.
  • The pilot became disoriented, reducing the likelihood of a successful turn back and precipitating the collision with terrain.

Other safety factors

  • The pilot did not fully plan the flight in accordance with the flight planning requirements, specifically with respect to fuel planning.
  • The current advice in Civil Aviation Advisory Publication 5.81-1(0) Flight Crew Licensing Flight Reviews in relation to the assessment of navigation skills, represents a missed opportunity to identify a pilot’s capacity to make safe and appropriate decisions during cross-country flying. [Minor safety issue]
  • The flight planning requirements at page 88 of the Visual Flight Guide included a transcription error that inadvertently limited the application of the requirements of Civil Aviation Regulation 239. [Minor safety issue]

Other key findings

  • The pilot's decisions not to submit any form of flight notification and not to replace the aircraft's emergency locator transmitter contributed to the delay and confusion in mounting an expeditious search and rescue.

Safety action

In respect of CAAP 5.81-1(0) and page 88 of the Visual Flight Guide, the Civil Aviation Safety Authority (CASA) took action to amend the CAAP and withdrew the Visual Flight Guide for amendment.

CASA’s response to the safety issues may be found at Safety Issues

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 involving VH-POJ.

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

The Coroner's report can be obtained from the Coroner's Court of NSW Contact details are available at: www.coroners.justice.nsw.gov.au. Queries regarding the Coroner's findings should be directed to the Coroner's Court of NSW.

 

 

Safety issues

AO-2008-083-SI-01 - AO-2008-083-SI-02 -  

Flight Review guidance

The current advice in Civil Aviation Advisory Publication 5.81-1(0) Flight Crew Licensing Flight Reviews in relation to the assessment of navigation skills, represents a missed opportunity to identify a pilot's capacity to make safe and appropriate decisions during cross country flying.

Safety issue details
Issue number:AO-2008-083-SI-01
Who it affects:Civil Aviation Safety Authority
Status:Adequately addressed


 

CASA Documentation

The flight planning requirements at page 88 of the Visual Flight Guide included a transcription error that inadvertently limited the application of the requirements of Civil Aviation Regulation 239.

Safety issue details
Issue number:AO-2008-083-SI-02
Who it affects:Civil Aviation Safety Authority
Status:Adequately addressed

 
General details
Date: 24 December 2008 Investigation status: Completed 
Time: 1600 ESuT Investigation type: Occurrence Investigation 
Location   (show map):Scone Aerodrome Occurrence type:Collision with terrain 
State: New South Wales Occurrence class: Operational 
Release date: 14 July 2010 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: Cessna Aircraft Company 
Aircraft model: 172 
Aircraft registration: VH-EKS 
Serial number: 17259908 
Type of operation: Private 
Damage to aircraft: Serious 
Departure point:Mudgee, NSW
Destination:Glen Innes, NSW
 
 
 
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Last update 02 March 2016