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On 18 April 2014, a Piper PA-27 aircraft, registered VH-DTL, departed Moorabbin, Victoria for Flinders Island, Tasmania, under the instrument flight rules (IFR), with five passengers and the pilot on board.

During climb, the aircraft entered cloud. When the aircraft momentarily exited cloud, the pilot observed the primary artificial horizon (AH) indicated level flight, while the aircraft was in a descending turn. The primary AH then settled and accurately reflected the aircraft state.

The aircraft was in cloud throughout the cruise and severe turbulence intermittently caused both AH’s to provide unstable indications. The pilot set up the GPS to track for the runway 05 RNAV (GNSS) approach to Flinders Island, via waypoint ‘FLIWC’.  

After passing the waypoint, the GPS did not sequence to the next waypoint. He then continued to fly the approach using AvPlan. When at about 1,000 ft AGL, the aircraft encountered heavy rain, the pilot was unable sight the runway and commenced a left turn to circle back to approach the runway.

When at about 500 ft AGL, the aircraft encountered severe turbulence, which resulted in a high angle of bank and the stall warning horn activating. With both AH’s not providing accurate information, the aircraft entered cloud.

The pilot contacted ATC and reported that the aircraft was in cloud with unreliable AH’s, GPS and ADF. The controller advised the pilot to turn onto a heading of 150° and climb to 8,000 ft AMSL to fly clear of the cloud. After about 20 minutes, the pilot observed the coastline, and elected to divert to Saint Helens aerodrome, Tasmania.

This incident highlights how unreliable or unserviceable instruments can increase pilot workload, particularly when in instrument meteorological conditions (IMC).


Aviation Short Investigations Bulletin - Issue 32

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[ Download PDF: 187KB]
General details
Date: 18 April 2014 Investigation status: Completed 
Time: 1235 EST  
Location   (show map):near Flinders Island Airport Investigation type: Occurrence Investigation 
State: Tasmania Occurrence type: Avionics/flight instruments 
Release date: 14 July 2014 Occurrence class: Technical 
Report status: Final Occurrence category: Serious Incident 
 Highest injury level: None 
Aircraft details
Aircraft manufacturer: Piper Aircraft Corp 
Aircraft model: PA-23-250 
Aircraft registration: VH-DTL 
Serial number: 27-4033 
Type of operation: Private 
Sector: Piston 
Damage to aircraft: Nil 
Destination:Flinders Island, Tas.
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Last update 14 November 2018