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What happened

On 15 August 2011, the pilot of a Piper PA‑28‑180 Cherokee aircraft, registered VH-POJ, was conducting a private flight transporting two passengers from Essendon to Nhill, Victoria under the visual flight rules (VFR). The flight was arranged by the charity Angel Flight to return the passengers to their home location after medical treatment in Melbourne. Global Positioning System data recovered from the aircraft indicated that when about 52 km from Nhill, the aircraft conducted a series of manoeuvres followed by a descending right turn. The aircraft subsequently impacted the ground at 1820 Eastern Standard Time, fatally injuring the pilot and one of the passengers. The second passenger later died in hospital as a result of complications from injuries sustained in the accident.

What the ATSB found

The ATSB found that the pilot landed at Bendigo and accessed a weather forecast before continuing towards Nhill. After recommencing the flight, the pilot probably encountered reduced visibility conditions approaching Nhill due to low cloud, rain and diminishing daylight, leading to disorientation, loss of control and impact with terrain. One of the passengers was probably not wearing a seatbelt at the time of the accident.

The ATSB also established that flights are permitted under the visual flight rules at night (night VFR) in conditions where there are no external visual cues for pilots. In addition, pilots conducting such operations are not required to maintain or periodically demonstrate their ability to maintain aircraft control with reference solely to flight instruments.

What's been done as a result

As a result of previous ATSB investigations the Civil Aviation Safety Authority (CASA) has drafted new legislation, effective 4 December 2013, requiring a biennial review for night VFR‑rated pilots. In addition, CASA has indicated that it will clarify the nature of what is meant by the term ‘visibility’ in dark night conditions, provide enhanced guidance on night VFR flight planning, and provide enhanced guidance on other aspects of night VFR operations. The ATSB issued a safety recommendation as a result of investigation AO-2011-102 for CASA to prioritise this initiative.

The ATSB is also producing an educational booklet in its Avoidable Accident Series related to visual flight at night. When released, this safety education booklet will highlight a number of the risks associated with night VFR flight and discuss strategies for their management.

Safety message

All operators and pilots considering night VFR flights should assess the likelihood of dark night conditions by reviewing the weather conditions, celestial illumination and available terrain lighting affecting their planned flight. A VFR flight in dark night conditions should only be conducted by a pilot with high instrument flying proficiency as there is a significant risk of losing control if attempting to fly visually in such conditions. Application by pilots of the recommendations in CASA advisory publication CAAP 5.13-2(0) will reduce the risks associated with visual flight at night.

Additionally, wearing seatbelts will reduce the likelihood and severity of injuries in an aircraft accident.

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Preliminary report released 20 September 2011

On 15 August 2011, a Piper Aircraft Inc. PA‑28‑180 aircraft, registered VH-POJ, was conducting a private flight between Essendon Airport, Victoria and Nhill Aerodrome, Victoria under the visual flight rules (VFR). On board were the pilot and two passengers. The purpose of the flight was to transport one of the passengers, who had been in Melbourne, Victoria for non-emergency medical reasons, back to Nhill.

VH-POJ departed Essendon at 1600 and the pilot made an unplanned landing at Bendigo, Victoria at 1649. The aircraft departed Bendigo for Nhill at 1711.

The weather in the area around the accident was reported by other pilots not to have been suitable for VFR flight in the late afternoon.

Witnesses in, and to the south west of, Warracknabeal, Victoria reported hearing and/or seeing a low-flying light aircraft from approximately 1800 onwards. At approximately 1820, a loud bang was heard.

The aircraft's emergency locator transmitter did not activate. Witnesses raised the alarm immediately, but the crash site was not found until two hours after the accident occurred; the police and emergency services arrived at the scene a further thirty minutes after that.

Although classified as a private operation, the flight had been organised as an 'Angel Flight' by the charity, Angel Flight™ Australia.

The draft investigation report was finalised and released to directly involved parties (DIPs) on 19 September 2013 for comment by 17 October. Feedback from those parties on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in early December 2013.

 

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ATSB response to the Coroner

The ATSB notes that the Victorian Coroner, Jacinta Heffey has recently released a finding into a fatal accident without holding an inquest. The Coroner agreed with the conclusion in the ATSB report published on 3 December 2013 regarding the likely cause of the accident and was satisfied that the safety issue identified by the ATSB investigation into the accident was appropriate. The Coroner also noted that the ATSB had made a recommendation to the Civil Aviation Safety Authority (CASA) in relation to that safety issue.

Circumstances of the accident

On 15 August 2011, the pilot of a Piper PA‑28‑180 Cherokee aircraft, registered VH-POJ, was conducting a private flight transporting two passengers from Essendon to Nhill, Victoria under the visual flight rules (VFR).

Global Positioning System data recovered from the aircraft indicated that when about 52 km from Nhill, the aircraft conducted a series of manoeuvres followed by a descending right turn. The aircraft subsequently impacted the ground at 1820 Eastern Standard Time, fatally injuring the pilot and one of the passengers. The second passenger later died in hospital as a result of complications from injuries sustained in the accident.

ATSB Findings

The ATSB found that the pilot landed at Bendigo and accessed a weather forecast before continuing towards Nhill. After recommencing the flight, the pilot probably encountered reduced visibility conditions approaching Nhill due to low cloud, rain and diminishing daylight, leading to disorientation, loss of control and impact with terrain. One of the passengers was probably not wearing a seatbelt at the time of the accident.

The ATSB also established that flights are permitted under the VFR at night (night VFR) in conditions where there are no external visual cues for pilots. In addition, pilots conducting such operations are not required to maintain or periodically demonstrate their ability to maintain aircraft control with reference solely to flight instruments.

Contributing factors

The pilot departed Bendigo for Nhill under the VFR with a high risk of encountering forecast cloud and dark night conditions and of subsequent loss of control due to loss of visual reference and probable spatial disorientation.

Aerial work and private flights were permitted under the VFR in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.

Other factors that increased risk

One of the passengers probably did not use the installed seatbelt, resulting in a greater risk of injury during the collision with terrain.

Safety issue - recommendation

The ATSB issued a safety recommendation to CASA that it prioritise its efforts to address the safety risk associated with aerial work and private flights as permitted under the VFR in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.

CASA’s response to the safety issue may be found at Safety Issue

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 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 issue

AO-2011-100-SI-01 -  

Requirements for visual flight rules flights in dark night conditions

Aerial work and private flights were permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.

Safety issue details
Issue number:AO-2011-100-SI-01
Who it affects:All aircraft operating under the night visual flight rules
Status:Safety action pending

 
General details
Date: 15 Aug 2011 Investigation status: Completed 
Time: 1820 EST Investigation type: Occurrence Investigation 
Location   (show map):31 km north Horsham Occurrence type:VFR into IMC 
State: Victoria Occurrence class: Operational 
Release date: 03 Dec 2013 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: Piper Aircraft Corp 
Aircraft model: PA-28 
Aircraft registration: VH-POJ 
Serial number: 28-2593 
Type of operation: Private 
Sector: Piston 
Damage to aircraft: Destroyed 
 
 
 
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Last update 01 March 2016