Inquest

Summary

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.