Aviation safety investigations & reports

Flight instrument issue involving a Piper PA-27, VH-DTL, near Flinders Island Airport, Tasmania, 18 April 2014

Investigation number:
Status: Completed
Investigation completed


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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

Download Final Report
[Download  PDF: 187KB]
Alternate: [Download  DOCX: 334KB]
General details
Date: 18 April 2014   Investigation status: Completed  
Time: 1235 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): near Flinders Island Airport    
State: Tasmania   Occurrence type: Avionics/flight instruments  
Release date: 14 July 2014   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

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.  
Last update 14 November 2018