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: Queries regarding the Coroner's findings should be directed to the Coroner's Court at Brisbane.