Aviation safety investigations & reports

VFR flight into dark night conditions and loss of control involving Cessna T210N, VH-MEQ, 2 km north-west of Roma Airport, Qld on 25 March 2013

Investigation number:
AO-2013-057
Status: Completed
Investigation completed

Summary

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What happened

At about 0518 Eastern Standard Time on 25 March 2013, a Cessna T210N aircraft, registered VH‑MEQ, took off in dark night conditions from runway 36 at Roma Airport on a flight to Cloncurry, Queensland. Following the activation of the aircraft’s emergency locator transmitter, a search was commenced for the aircraft by the Australian Maritime Safety Authority. It was subsequently located 2 km to the north‑west of the airport, having collided with terrain while heading in a south-westerly direction. The aircraft was destroyed and the pilot and passenger were fatally injured.

What the ATSB found

The ATSB found that the departure was conducted in dark night conditions, despite the pilot not holding a night visual flight rules rating and probably not having the proficiency to control the aircraft solely by reference to the flight instruments. During the climb after take-off, the pilot probably became spatially disorientated from a lack of external visual cues, leading to a loss of control and impact with terrain.

No mechanical defect was identified with the aircraft or its systems that may have contributed to the accident.

Safety message

This accident reinforces the need for day visual flight rules pilots to consider the minimum visual conditions for flight, including the relevant weather information and usable daylight. In this case, if the pilot had delayed the departure by 30 minutes, the flight would most likely have progressed safely in daylight conditions.

There are numerous airports in Australia, including Roma, that have an abundance of ground lighting in one take-off direction but not another. This accident highlights the potential benefits of night visual flight rules and instrument-rated pilots considering the location of ground lighting when planning night operations.

Finally, the benefit of crash-activated emergency locator transmitters that include global positioning system-based location information, thereby providing for a timely emergency response in the event of an accident, is emphasised.

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Inquest

Response to Inquest Findings

The Coroner’s Court of Queensland, without holding an inquest, recently made findings into a 2013 fatal accident involving a Cessna T210N aircraft near Roma Airport.

The ATSB summary explains that on 25 March 2013, the pilot of a Cessna T210N aircraft and a passenger took off from Roma airport to the north about 30 minutes before dawn. The aircraft crashed descending in a left turn about 2 km north-west of the airport. There was no indication of any mechanical defects in the aircraft, however the pilot was not qualified to fly at night.

The Coroner adopted the Sequence of Events as set out in the Australian Transport Safety Bureau final report in relation to how the accident occurred and incorporated into his findings those of the ATSB regarding the likelihood of pilot spatial disorientation.

The Coroner stated:

Unfortunately for reasons that are currently unknown [the pilot] decided to take-off in darkness only 30 minutes from first light. The ATSB considers he suffered from the well known phenomenon of spatial disorientation and the plane crashed into the ground causing his death and that of his passenger.

Safety message

This accident reinforces the need for day visual flight rules pilots to consider the minimum visual conditions for flight, including the relevant weather information and usable daylight. In this case, if the pilot had delayed the departure by 30 minutes, the flight would most likely have progressed safely in daylight conditions.

There are numerous airports in Australia, including Roma, that have an abundance of ground lighting in one take-off direction but not another. This accident highlights the potential benefits of night visual flight rules and instrument-rated pilots considering the location of ground lighting when planning night operations.

Finally, the benefit of crash-activated emergency locator transmitters that include global positioning system-based location information, thereby providing for a timely emergency response in the event of an accident, is emphasised.

Inquests are separate to ATSB investigations

The Coroner formulated his findings and recommendations independently of the ATSB. The ATSB cannot speak for the Coroners findings. However, the ATSB supports the coronial process and in the interests of ensuring that safety information is made available to the broadest audience the ATSB is making this publication.

The Coroner's report is expected to be made available from the Coroner's Court of Queensland. Contact details are available at: www.courts.qld.gov.au/courts. Queries regarding the Coroner's findings should be directed to the Coroner's Court at Brisbane.

General details
Date: 25 March 2013   Investigation status: Completed  
Time: 0519 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): 2 km north-west of Roma Airport, Queensland    
State: Queensland   Occurrence type: Collision with terrain  
Release date: 16 September 2014   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 210  
Aircraft registration VH-MEQ  
Serial number 21064869  
Type of operation Private  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Roma, Qld  
Last update 14 November 2018