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What happened

On the morning of 29 January 2016, a Piper Aircraft Corp PA-28 aircraft, registered VH-PXD, was on a private flight from Moorabbin Airport, Victoria to King Island, Tasmania. After passing over Point Lonsdale, the aircraft entered an area of low visibility. The pilot conducted a 180° turn and initially tracked back towards Point Lonsdale, before heading south over the ocean. After about 2 minutes, the aircraft was again turned right before entering a rapid descent. The aircraft impacted the water at 1227 Eastern Daylight-saving time, 6.6 km south-west of Point Lonsdale. All four occupants of the aircraft were fatally injured.

What the ATSB found

The ATSB found that continuation of the flight beyond Point Lonsdale, and towards an area of low visibility conditions, was likely influenced by the inherent challenges of assessing those conditions.

The ATSB also found that due to the presence of low cloud and rain, the pilot probably experienced a loss of visual cues and became spatially disorientated, leading to a loss of control and impact with the water. The risk of a loss of control in the conditions was increased by the pilot’s lack of instrument flying proficiency.

Safety message

Pre-flight planning needs to include consideration of not only the conditions on departure, but at all stages of the flight. This informs the decision of whether to depart and allows for prior consideration of alternative actions in the case of deteriorating weather, such as returning or diverting.

It is always possible that the actual weather conditions will be different to those forecast. Pilots conducting a flight under the visual flight rules make every effort to avoid areas of low visibility and plan for unforeseen eventualities. However, this is dependent on the pilot perceiving the risks of the situation, which is not inherently easy. Education and training in the practical application of meteorological principles has been shown to enhance pilots’ ability to recognise and respond to deteriorating weather conditions.

The ATSB cautions that, on entering an area of reduced visual cues, the risk of experiencing spatial disorientation and a loss of control is high, measuring from between 60 to 178 seconds from the time of entering the area of low visibility. This risk is highest for those without proficiency or recent experience in instrument flying. Requesting assistance from air traffic control can increase the chances of re-establishing visual cues.

Download Final Report
[ Download PDF: 2.12MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Sources and submissions

 
General details
Date: 29 January 2016 Investigation status: Completed 
Time: 12:27 ESuT Investigation type: Occurrence Investigation 
Location   (show map):33 km south-south-east of Avalon Airport Occurrence type:Loss of control 
State: Victoria Occurrence class: Operational 
Release date: 28 June 2017 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 
Aircraft details
Aircraft manufacturer: Piper Aircraft Corp 
Aircraft model: PA-28-235 
Aircraft registration: VH-PXD 
Serial number: PA-28-235  
Type of operation: Private 
Sector: Piston 
Damage to aircraft: Destroyed 
Departure point:Moorabbin Airport, Victoria
Destination:King Island, Tasmania
 
 
 
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Last update 14 July 2017