Summary video

The occurrence

On 20 July 2025, a Reims Aviation F406 Caravan II, registered VH-EYQ, was being utilised for an instrument proficiency check (IPC)[1] with a pilot and a flight examiner on board. The flight was conducted under the instrument flight rules[2] and the planned route was from Warwick Airport to Oakey Airport, Queensland, later returning to Warwick Airport. 

The IPC was the pilot’s third flight for the day. They had undertaken an aerial survey mission in VH-EYQ that morning for Aero Logistics, having departed Emerald Airport, Queensland, at 0747 and arrived at Archerfield Airport, Queensland, at 1208. The pilot refuelled the aircraft at Archerfield Airport and departed at 1308 for the flight to Warwick Airport for the purposes of undertaking the IPC. 

The pilot arrived at Warwick Airport at 1345 where they met the flight examiner. At 1426, the aircraft departed Warwick Airport. About 16 seconds after departure, the aircraft’s groundspeed began to decrease from 109 kt, and the aircraft stopped climbing and commenced a slow turn to the right (Figure 1). This turn was not consistent with the submitted flight plan. The aircraft’s groundspeed continued to reduce over a period of about one minute to 80 kt (see Recorded flight data). The aircraft then began to accelerate before turning left and commencing a climb to an altitude of 6,100 ft above mean sea level. 

Figure 1: VH-EYQ departure from Warwick Airport

Source: Google Earth, annotated by the ATSB

At 1433, Brisbane Centre air traffic control (ATC) issued the pilot with a clearance to track directly to reporting point[3] NUTPA, which was the commencement point for the Oakey Airport runway 14 instrument landing system (ILS)[4] approach (Figure 2).

Figure 2: VH-EYQ flight overview

Source: Google Earth, annotated by the ATSB

At 1439, the pilot advised ATC that they would be conducting airwork in the Oakey area, not above an altitude of 4,000 ft, and they would contact ATC again on completion or by 1530. At that time, the Oakey Airport ATC tower was inactive. After commencing the descent for NUTPA at 1441, the pilot changed frequency to the common traffic advisory frequency (CTAF) in the Oakey Airport area, and all subsequent air-to-air communications took place on the CTAF. Between 1443 and 1454 the pilot made 5 transmissions on this frequency for traffic sequencing purposes. 

At 1450, the aircraft passed overhead NUTPA and conducted one holding pattern. At 1456, the aircraft commenced a descent from 3,800 ft and the pilot made a radio broadcast to advise that the aircraft was established on the ILS. 

At 1457, the aircraft began to deviate from the horizontal profile for the approach. The aircraft initially deviated right of the extended centreline and then to the left (Figure 3). Fluctuations in vertical speed also occurred during this period. The aircraft continued the approach slightly left of the extended centreline, but the vertical profile of the approach remained on the glideslope.[5] The wind conditions recorded at Oakey Airport at the time were a light breeze of 6 kt, with a mean direction of 190°M (see Meteorological information).

Figure 3: Final approach track

Source: Google Earth, annotated by the ATSB

At about 1458:45, and an altitude of 2,500 ft, the aircraft began to descend below the glideslope. This was initially corrected, and the aircraft flew level at about 2,200 ft for 30 seconds. At 1459:25, the aircraft descended below the glideslope again, and the descent continued to an altitude of about 1,700 ft, which equated to a height of between 300–400 ft above ground level (AGL). During this period the aircraft’s groundspeed began to decay. At 1459:39, the aircraft’s groundspeed had reduced to 85 kt (see Recorded flight data). At about 1459:53,[6] a 2‑second radio broadcast was made from the aircraft with an alarm sounding in the background.

A motorist travelling south observed the aircraft on approach and maintained visual contact with it for about 3 km (Figure 4). They observed the aircraft commence a flat turn and yaw[7] to the left at a height of about 300 ft AGL and pass above the road ahead of them. They recalled seeing the aircraft then roll to the left, pitch down, and impact the terrain. 

Figure 4: Witness and closed-circuit television camera locations

Source: Google Earth, annotated by the ATSB

Closed-circuit television (CCTV) cameras located at a nearby property and Oakey Airport captured the aircraft commence a steep descent before colliding with terrain (Figure 5).

The aircraft was destroyed in a post-impact fire, and both occupants were fatally injured.

Figure 5: Composite images of recorded CCTV camera footage

Source: CCTV camera recordings

Context

Pilot information

Pilot experience

The pilot held a valid class 1 aviation medical certificate and an air transport pilot licence (ATPL) (aeroplane). Additionally, they held a grade 3 flight instructor rating with multi‑engine aeroplane training approval and design feature endorsements to operate VH-EYQ. The pilot held a valid multi-engine instrument rating with the previous instrument proficiency check (IPC) completed in August 2024. 

At the time of the accident, the pilot had accumulated 5,767 hours total aeronautical experience. This included 4,170 flight hours as pilot in command with 3,514 hours in multi-engine aeroplanes and about 1,200 hours in command of a Reims F406. In the preceding 90 days they had flown 95 hours, including 54 hours in the Reims F406. They had worked for the aircraft operator since March 2017.

Known recent activity

The pilot’s work roster for the week prior to the accident (from 14 to 20 July 2025) is shown in Table 1. During this week, the pilot was based away from home and conducted multiple survey flights. The pilot’s duties for 20 July included the survey flight in the morning with no additional rostered flying.

Table 1: Pilot rostered duties, 14 to 20 July 2025

A text message sent from the pilot the evening of 19 July indicated that the pilot had intended to conduct the IPC the following day. Additionally, the message indicated they had sleep opportunity from about 2130. 

Flight examiner information

Flight examiner experience

The flight examiner held a valid class 1 aviation medical certificate and an ATPL (aeroplane). They also held grade 1 flight instructor and flight examiner operational ratings, with multi-engine aeroplane and instrument rating (aeroplane) training approval. Their flight instructor rating also had a spin endorsement, and they held design feature endorsements to operate VH-EYQ. The examiner held a valid multi-engine instrument rating with the previous IPC completed in October 2024.

The flight examiner’s logbook records were destroyed in the post-impact fire. Based on records of the pilot’s hours from January 2025, the flight examiner’s total aeronautical experience was in excess of 20,000 hrs. Additionally, they had flown 3 similar proficiency check flights for the aircraft operator in the previous 12 months, totalling 3.6 hours in the Reims F406. The flight examiner was external to the aircraft operator and was regularly hired to complete the IPC for their pilots.

Known recent activity

Along with their logbook, the flight examiner's work records were destroyed in the post‑impact fire. 

A family member recalled that the flight examiner had returned from a chartered flight to western Queensland on Tuesday 15 July. During the week, they had spent a day providing aviation theory instruction to students but had no other work engagements. On the day of the accident, the flight examiner woke at their normal time. They were reported to have slept well and, when leaving home for the IPC flight, they appeared their normal self with no signs of fatigue.

Aircraft information

General information

The Reims Aviation F406 is a low wing, twin‑engine aircraft powered by 2 Pratt & Whitney Canada PT6A-112 turbine engines, each driving a 3-bladed McCauley constant speed, full-feathering propeller (Figure 6). The accident aircraft, serial number F406‑0047, was manufactured in France in 1990 and first registered in Australia as VH‑EYQ in 2012. 

Figure 6: Reims F406

Source: ASI Aviation

Recent maintenance activity

The aircraft was to be maintained in accordance with the aircraft operator’s Civil Aviation Safety Authority (CASA) approved system of maintenance. This required a periodic inspection every 100 hours or 12 months, whichever came first. The system of maintenance allowed for periodic inspection intervals to be extended up to a maximum of 10 hours. The most recent periodic inspection was completed on 11 June 2025, at 17,376 hours in service. At the time of the accident, the aircraft had accumulated 17,475.6 hours total time in service.

Configuration

VH-EYQ was configured in a 5-seat survey layout. This comprised the pilot (left) and copilot (right) seats in the front row, followed by 1 passenger seat in row 3, and 2 passenger seats in row 5. The remaining passenger seats were removed from the cabin to accommodate the installation of aerial survey equipment (Figure 7). An electronic loading system had been generated for this configuration by an approved load controller, and records show that this was utilised by the pilot for previous flights.

Figure 7: VH-EYQ cabin configuration

Source: ASI Aviation, annotated by the ATSB

Weight and balance

Prior to its departure from Archerfield Airport, the aircraft was fuelled with 1,086 L of Jet A1 fuel. The aircraft operator advised that, based on this fuel uplift and the intended flying activity, it was very likely that the aircraft had full fuel on board for the flight to Warwick Airport. Fuel calculations based on flight times and expected consumption rates indicated that, at the time of the accident, the aircraft probably had about 1,280 L of fuel on board. This meant the aircraft weight at the time of the accident was about 600 kg below the aircraft’s maximum take-off weight. Based on the survey flying configuration and loading of the aircraft, the aircraft’s centre of gravity was calculated and assessed to be within prescribed limits.

Performance

The pilot operating handbook airplane flight manual (POH) provided applicable limitations which included:

• a stall speed[8] of 75 KIAS[9] in the landing configuration (V_SO), and 94 KIAS with flaps in the up position (V_S)
• an intentional one engine inoperative speed (V_SSE)[10] of 98 KIAS
• an air minimum control speed (V_MCA)[11] of 90 KIAS
• a one engine inoperative best rate-of-climb speed at sea level (V_YSE) of 108 KIAS. 

One engine inoperative procedures

The POH included recommended procedures in the event of an emergency. This included checklists for an engine failure in flight, and for the conduct of an approach and missed approach with one engine inoperative. The recommended approach speed with an engine inoperative was 110 KIAS reducing to 101 KIAS only once landing was assured.

Site and wreckage information

Accident site

The ATSB conducted an onsite examination of the aircraft wreckage, which was located in an open paddock about 2.6 km from the threshold of runway 14 at Oakey Airport (Figure 8).

Figure 8: Location of accident

Source: Google Earth, annotated by the ATSB

The wreckage was confined to a 30 m radius of the accident site. The impact marks and wreckage position indicated the aircraft impacted terrain left wing low with little forward momentum. Ground scars indicated the aircraft moved about 6 m after the initial impact. All components were upright.

The tail and aft cabin section showed signs of vertical compression. There was no fore or aft compression damage to the nose or wings. The left wing had separated from the aircraft just outboard of the left engine, and the right wing had separated just inboard of the right engine. Both wings had swung forward to lay parallel to the fuselage (Figure 9).

Figure 9: VH-EYQ accident site

Source: ATSB

All major aircraft components were accounted for at the point of impact. A post‑impact fire consumed the forward section of the aircraft to the aft cabin door (Figure 10). This damage limited the extent to which pre-impact defects could be identified.

Figure 10: VH-EYQ wreckage

Source: ATSB 

Engines

Both engines were retained for further examination. This was conducted by ATSB investigators who were assisted by investigators from Pratt & Whitney Canada.[12] The engine examination determined: 

• there were no indications of pre-impact mechanical anomalies to any of the engine components that would have precluded normal engine operation
• the left engine displayed indications that it was rotating at the time of impact
• the right engine displayed characteristics that it was developing power at the time of impact.

Propellers

Both propellers showed indications that the engines were running at impact. The right propeller was determined to be in a fine pitch position[13] and exhibited bending in multiple directions.

Both propellers were retained, and an independent inspection was carried out at a propeller overhaul facility under the direction of ATSB investigators. Further analysis is required to determine the position of the left propeller at the time of impact.  

Meteorological information

The Bureau of Meteorology (BoM) graphical area forecast valid at the time of the accident included the following conditions en route:

• scattered cloud bases of 3,000 ft to 5,000 ft, extending up to 8,000 ft
• isolated showers of rain with broken cloud from 1,000 ft to 2,000 ft and scattered cloud from 2,000 ft to above 10,000 ft.

At 1500, at about the same time the aircraft impacted terrain, the BoM issued a meteorological aerodrome report for Oakey Airport which reported the conditions at that time were:

• a wind of 6 kt, with a mean direction of 190°M, varying between 160°M–220°M
• visibility of 10 km or greater
• no cloud detected
• a temperature of 20°C and a dew point of 6°C
• a QNH[14] of 1,016 millibars
• no recorded rainfall since 0900.

Satellite images and CCTV footage captured areas of scattered cloud in the vicinity of the aerodrome at the time of the approach.

Flight activity

General

For a pilot to operate an aircraft under the instrument flight rules, they are required to hold an instrument rating. Pilots are also required to pass an annual instrument proficiency check (IPC) flight to ensure that they maintain the necessary skills and competency to operate safely. The purpose of the accident flight was for the pilot to complete their annual IPC. 

An IPC can be completed by a flight examiner with an instrument rating, MPL[15] or ATPL (aeroplane) flight test endorsement, or by a person approved by CASA. While the aircraft operator had a training and checking system,[16] they scheduled IPC flights with external examiners and permitted the pilots to arrange their IPC flights privately. The head of flying operations (HOFO) of the aircraft operator recalled that the accident pilot had advised them that their IPC expiry date was approaching and requested the use of VH‑EYQ to complete the flight. In response, provisions were made by the HOFO and head of aircraft airworthiness and maintenance control delegate to make the aircraft available to the pilot for the purpose of conducting the IPC flight. 

The pilot arranged the IPC with the external flight examiner and records show that the IPC was booked into the CASA flight test management system[17] by the flight examiner during the afternoon of 18 July and scheduled to take place on the afternoon of 20 July. 

Instrument proficiency check assessment

During an IPC flight, a pilot’s competency is assessed in actual or simulated instrument meteorological conditions. During the flight, a pilot is required to meet specified standards for:

• departure
• en route skills
• arrival
• approach
• missed approach
• approach to land manoeuvres.

If the IPC is for multi-engine operations, the assessment also requires the satisfactory completion of a simulated one engine inoperative (OEI) departure and a simulated OEI approach. 

The HOFO of the aircraft operator recalled that the external flight examiner had, in the past, typically conducted the simulated OEI departure after take-off from Warwick Airport and the simulated OEI approach at Oakey Airport. 

Recorded information

Recorded flight data

The aircraft was not fitted with a flight data recorder or a cockpit voice recorder, nor was it required to be. During the accident flight, data was being transmitted by the aircraft’s automatic dependent surveillance broadcast (ADS-B) equipment. This data, recorded at 2–5 second intervals by amateur ground-based receivers, captured the aircraft’s position, altitude and groundspeed during the flight. Flight data was also being transmitted from a Spidertracks[18] tracking device fitted to the aircraft. This data, recorded at 15-second intervals, captured the aircraft’s position, altitude, groundspeed and heading during the flight.

The ADS-B altitude and groundspeed data for the aircraft’s departure from Warwick Airport is depicted in Figure 11.

Figure 11: VH-EYQ altitude and groundspeed during the Warwick Airport departure

Source: ATSB 

The ADS-B altitude and groundspeed data for the aircraft’s ILS approach at Oakey Airport is depicted in Figure 12.

Figure 12: VH-EYQ altitude and groundspeed during the Oakey Airport approach

Source: ATSB 

A Garmin GTN-650 global positioning system was also recovered from the accident site and transported to the ATSB’s Canberra technical facility for further examination. The unit showed signs of significant heat damage with melting and evidence of charring on the internal circuitry. The remains of 2 SD[19] cards were found within the unit, however, the post-impact fire had damaged the SD card memory chips to the point that data could not be extracted using normal recovery methods. 

Record radio communications

All radio communications made and received by Airservices Australia throughout the entirety of VH-EYQ’s flight from Warwick Airport were recorded.

Recorded CCTV footage

Two CCTV cameras captured footage of the aircraft immediately prior to the collision with terrain. One camera was located on a property 1.4 km to the north-west of the accident and the second camera was located on Oakey Airport about 3 km south of the accident site. 

The property CCTV footage was timestamped. The aircraft entered frame at 1459:53 and remained in frame for the duration of the recording which captured the collision with terrain at 1500:00.

The Oakey Airport CCTV footage did not contain a timestamp. The aircraft entered frame 1 second into the recording and remained in frame until the collision with terrain that occurred 7 seconds later.

Further investigation

To date, the ATSB has:

• examined the wreckage and accident site
• examined meteorological information
• interviewed relevant parties
• collected radio communication, aircraft traffic surveillance data, and navigational application data
• collected aircraft, pilot, crew and operator documentation.

The investigation is continuing and will include review and examination of:

• pilots’ recent history
• propellers
• maintenance records
• pilot and crew training and medical records
• operational procedures and documentation
• further interviews with relevant parties
• flight data and air traffic surveillance data
• the requirements of conducting simulated one engine inoperative exercises at low heights.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken. 

Acknowledgements

The ATSB would like to acknowledge the assistance provided by the Australian Defence Force personnel at the Oakey Army Aviation Centre during the initial evidence collection activities.

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through:  identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. About ATSB reports ATSB investigation reports are organised with regard to international standards or instruments, as applicable, and with ATSB procedures and guidelines. Reports must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2025 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Commonwealth Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this report is licensed under a Creative Commons Attribution 4.0 International licence. The CC BY 4.0 licence enables you to distribute, remix, adapt, and build upon our material in any medium or format, so long as attribution is given to the Australian Transport Safety Bureau.  Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

Investigation summary

What happened

On 15 July 2025, a Beechcraft 35-C33 Debonair, registered VH-KZK, departed Wangaratta Airport, Victoria for a private flight under the visual flight rules (VFR) to Moruya Airport, New South Wales. 

Soon after entering the Snowy Mountains area, the aircraft made a 150° right turn, shortly followed by another long left turn. The aircraft entered a spiralling descent to the right that continued until the aircraft collided with terrain. The pilot was fatally injured and the aircraft was destroyed.

What the ATSB found

It is very likely that the pilot, who did not hold an aircraft instrument rating, experienced spatial disorientation after flying into instrument meteorological conditions (IMC). This subsequently resulted in the collision with terrain.

Based on the forecast cloud between Wangaratta and Moruya, completing such a flight while maintaining VFR was likely not feasible. The pilot held a recreational pilot licence that did not include a navigation endorsement. While the pilot had completed some of the training required to attain a navigation endorsement, it is possible that the pilot’s limited training and experience in this respect affected their decision to conduct or continue the flight into challenging weather conditions.

Safety message

One of the key risk controls for a VFR pilot to avoid entering IMC is appropriate pre-flight preparation and planning. Not only should pilots obtain up-to-date weather information before and during flight, they should plan an alternate landing point and be prepared to make necessary deviations from the planned route should actual weather conditions necessitate it.

Licence restrictions and endorsements are a critical aspect of flight safety. They ensure that pilots have been trained to an acceptable standard and that the appropriate experience has been attained. Studies show that pilots with less weather experience are more likely to engage in high-risk activities when dealing with weather. This accident is an important reminder to respect these restrictions and endorsements when planning a flight.

The investigation

The occurrence

On 15 July 2025, the pilot and sole occupant of a Beechcraft 35-C33 Debonair, registered VH-KZK, was conducting a private flight under the visual flight rules (VFR)[1] from Wangaratta Airport, Victoria, to Moruya Airport, New South Wales. The pilot was returning to Moruya following the completion of routine maintenance on the aircraft.

It is not known what weather information was accessed by the pilot prior to departing Wangaratta, as no flight planning records were recovered. Text messages from the pilot at 0755 on the morning of the accident flight indicated that they were conducting flight planning and considering the weather on the morning of the accident flight, noting that ‘the sky outside is scattered clouds so we will see what the planning forecast is.’

A flight path recreated from automatic dependant surveillance broadcast (ADS-B) transmissions is shown in Figure 1. The pilot departed Wangaratta at 1302 and flew approximately east towards Moruya, 189 NM away, making occasional changes in heading. By 1315 the aircraft had climbed to an altitude of 4,500 ft above mean sea level (AMSL), where it remained until it approached the rising terrain of the Snowy Mountains, where the aircraft began climbing to 7,000 ft. The mountainous area along the aircraft’s flight path had varying terrain heights, with a maximum of approximately 6,000 ft AMSL.

Figure 1: Flight path of VH-KZK on 15 July 2025

Source: Google Earth, annotated by the ATSB

The aircraft flew past a small aerodrome, Khancoban Airport,[2] at about 1339 at an altitude of about 6,400 ft AMSL (Figure 2). At 1340:15, the pilot commenced a rate 1 turn[3] to the right with minimal change in altitude. At 1341:18, after turning through 150°, there was a 20-second period where ADS-B transmissions were not received. The aircraft was subsequently detected in a left turn through 206°, also approximately rate 1. An airspeed of approximately 150 kt was maintained through these turns. 

Figure 2: Flight path prior to colliding with terrain

Vertical lines are used to indicate the aircraft’s height above terrain. Each line represents a data point. Source: Google Earth, annotated by the ATSB

At approximately 1342:38, the aircraft entered another right turn and shortly after, began descending from 6,725 ft AMSL. From this point, the aircraft’s rate of turn, descent rate and groundspeed all steadily increased into a spiralling descent. The last ADS-B transmission was recorded 55 ft above ground level, with an estimated airspeed of 210 kt and a rate of descent above 4,000 ft/min. At 1343:40, the aircraft collided with terrain at an elevation of 4,830 ft AMSL. The pilot was fatally injured and the aircraft was destroyed. 

The pilot had lodged a search and rescue time (SARTIME) with Airservices Australia, and when this time elapsed the Joint Rescue Coordination Centre (JRCC) was notified and commenced a search. The aircraft was not fitted with an emergency locator transmitter (ELT), and poor weather conditions limited JRCC search capabilities. Visibility was affected by cloud, and in the early stages of the search, helicopters had limited access to the area where the aircraft was last detected on ADS-B. After an extended search by air, the aircraft was located on 17 July in steep, forested terrain with snow cover.

Context

Pilot information

General information

The pilot held a Recreational Pilot (Aeroplane) Licence (RPL) with a single engine aeroplane class rating and a flight radio endorsement. The RPL permitted private or training flights by day under VFR. The pilot was issued with a basic class 2 aviation medical certificate that was valid until February 2026. The basic class 2 medical certificate was an alternative to a full class 2 certificate for RPL and Private Pilot Licence (PPL) holders. It imposed additional operational restrictions, including that the pilot was not permitted to fly above 10,000 ft. 

The pilot’s next of kin reported no relevant medical conditions or medications. There was evidence that the pilot had up to about 9 hours sleep opportunity the night before the flight, but there was insufficient information available to assess fatigue.

Toxicology and pathology reports were not available at the time of publishing this report.

Training and experience

The ATSB estimated[4] the pilot had completed 142 hours total flight time, including 28 hours of solo flying. The pilot had an estimated 25 hours of flight experience in the Beechcraft 35-C33 Debonair, entirely in VH-KZK (which they owned), including 10 hours of solo flying.

The pilot did not have an RPL navigation endorsement, which meant they were restricted from flying beyond 25 NM of the departure aerodrome, unless it was to travel to a training area. Obtaining the navigation endorsement required completion of specific flying training and passing a written examination. The Civil Aviation Safety Authority (CASA) website stated that the examination covered a range of topics including:

• maps and charts properties

• forecast requirements and interpretation of forecasts, determination of alternate or holding requirements.

The pilot had received some navigation training, which included several navigation exercises, as well as a solo navigation flight. Including that flight, the pilot had completed 4 exercises within the standard PPL syllabus. Two additional dual exercises and 1 final long solo navigation exercise were required before an RPL navigation endorsement could be sought. During the training, with regard to flight planning, the pilot was assessed as having achieved ‘competency to the standard required for qualification issue’. Flight planning included the following elements:

• select a suitable route and altitude considering weather, terrain, airspace, NOTAMs[5] and alternate landing areas

• obtain and interpret meteorological forecasts, NOTAMs and operational information applicable to the planned flight

• determine whether the planned flight can be conducted under the applicable flight rules and taking account of the beginning and end of daylight times.

In total, the pilot had accrued 38.1 hours of navigation training, including 1.7 hours flying solo. The pilot had also received 1.0 hours of basic instrument flight training in 2021 on a different aircraft.

Recent flying

The pilot’s most recent formal navigation training was in March 2023. Between November 2023 and October 2024, the pilot undertook training in VH-KZK, having previously flown a Beechcraft C23 Sundowner. Following this training, ADS-B data showed VH-KZK flying (determined to be with this pilot in command) on 9 different occasions between November 2024 and May 2025. All of these flights took place along the New South Wales south coast between Moruya Airport, Merimbula Airport and Frog’s Hollow Airfield (Figure 3). Logbook entries for these flights were not found, but they were understood to be solo flights for pleasure and personal transport.

Figure 3: Aerodromes used by VH-KZK

Source: Google Earth, annotated by the ATSB

On the day before the accident, the pilot conducted a solo navigation flight from Frog’s Hollow to Wangaratta Airport where the aircraft was booked in for routine maintenance. Weather forecasts from the area predicted a cloud ceiling of 7,000 ft and scattered cloud. ADS-B data showed that the pilot conducted most of the flight at an altitude of 9,000 ft, above the forecast cloud tops. The flight appeared to be conducted without incident.

Aircraft information

The Beechcraft 35-C33 Debonair is a low-wing, 4-seat, all-metal aircraft with retractable tricycle landing gear. The Debonair, with a conventional vertical fin and tailplane, was a variant of the early Beechcraft Bonanza model, which had a distinctive V-tail. VH-KZK, serial number CD-985, was manufactured in 1967 in the United States and first registered in Australia in the same year. It was powered by a 6-cylinder Teledyne-Continental Motors IO-470-K engine driving a McCauley 2A36C23 constant-speed propeller. The aircraft was fitted with a pitot heat system.

The aircraft had been classified as capable of operating under the instrument flight rules (IFR) in September 2019. A review of the expired maintenance releases identified that the aircraft shifted between IFR and VFR categories, depending on IFR inspection status. The last IFR inspection recorded in the aircraft logbook was completed on 4 May 2023, with the maintenance release showing the IFR category selected. The current maintainer, who first inspected the aircraft in June 2024, reported that, due to uncertainty around the certification of the equipment, the IFR category was not indicated on the previous 2 maintenance releases.

The aircraft was being maintained in accordance with the standard CASA maintenance schedule (Schedule 5), which required a periodic inspection every 100 flight hours or 12 months, whichever came first. The most recent periodic inspection was completed on 15 July 2025, with the aircraft having accrued 17.5 hours in the previous 12 months. In addition to the periodic inspection requirements, the 2 main tyres were replaced. A new maintenance release was issued with the aircraft having accrued 3,279 hours total time in service.

Maintenance records indicated that an emergency locator transmitter (ELT) was removed from the aircraft in 2019. The maintainer confirmed that there was no ELT fitted to VH-KZK.

Wreckage and impact information

Access to the accident site was limited due to the terrain, snow and environmental conditions, and the ATSB did not attend the accident site. New South Wales Police Force personnel who winched to the site via helicopter to recover the pilot took photographs and collected physical evidence, including documentation and potential data recording devices, which were later examined by the ATSB. 

The aircraft was significantly disrupted (Figure 4), consistent with the estimated final aircraft speed of 210 kt and a vertical rate of descent of over 4,000 ft/min. The impact was not survivable. Accident site photographs indicated that the wreckage was relatively contained, rather than spread over a long wreckage trail. This was consistent with the steep descent indicated by the flight data. The engine had separated from the aircraft wreckage and was located 10–15 m away. From the photographs, it was not possible to determine conditions such as aircraft configuration, control cable continuity or the state of control surfaces. It also could not be determined whether all components remained attached up to the point of impact.

Figure 4: Wreckage of VH-KZK

Source: New South Wales Police Force

Meteorological information

Aerodrome weather

The aerodromes closest to the accident site were Khancoban Airport and Corryong Airport (7 NM and 18 NM west of the accident site, respectively). Corryong did not provide meteorological observations and Khancoban had a non-aviation automatic weather station which did not report cloud or visibility. However, records for Albury Airport (Figure 3), which VH-KZK passed earlier in the flight, indicated that the following conditions existed at 1330:

• visibility greater than 10 km
• 9 kt westerly wind
• no precipitation
• broken cloud at 4,600 ft AGL (5,100 ft AMSL).

Weather forecasts

The Bureau of Meteorology (BoM) issued a set of graphical area forecasts (GAFs) at 0820 on the morning of the accident flight. Based on the flight data, the aircraft’s flight path would have passed through 3 areas with varying forecast conditions.

For the initial part of the flight, beginning at Wangaratta and approaching the Victoria/New South Wales border, the terrain elevation along the flight path varied between about 500 and 3,800 ft AMSL. On this segment the following conditions were forecast (all altitudes are AMSL):

• a broken[6] cloud layer from 1,000–2,000 ft that was forecast to clear by about the aircraft’s departure time
• broken cloud from 3,000–8,000 ft
• isolated showers of rain, during which visibility would reduce to 4,000 m and cloud would extend from 800 ft to above 10,000 ft
• isolated showers of snow above 4,000 ft during which visibility would reduce to 500 m and cloud would extend to 8,000 ft
• freezing level above 4,500 ft.

After crossing into New South Wales and over the Snowy Mountains, just beyond Khancoban, the flight overflew mountainous terrain where the elevation increased to between 600 and 6,000 ft. In this region the forecast was for:

• scattered[7] cloud from 1,500–3,000 ft and broken cloud from 3,000 ft to above 10,000 ft
• scattered areas of drizzle with visibility reducing to 3,000 m and overcast conditions from 3,000 ft to 9,000 ft
• isolated showers of snow above 4,000 ft with broken cloud from 4,000 ft to above 10,000 ft
• freezing level above 4,500 ft.

The accident occurred within this region of the GAF. East of the highest terrain in the Snowy Mountains, conditions were forecast to improve slightly:

• scattered cloud from 2,500–8,000 ft
• broken cloud from 6,000 ft to above 10,000 ft.

Satellite imagery

A satellite photograph taken at 1340, less than 4 minutes before the aircraft collided with terrain, showed cloud cover in the vicinity of the accident site (Figure 5). However, the image provided no information on cloud height or density.

Figure 5: Satellite image from 1340 on 15 July

Source: Bureau of Meteorology, annotated by the ATSB.

Witness report

A witness with an aviation background was located near Khancoban Airport around the time of the occurrence. They reported hearing an aircraft in the area that they later believed to be VH-KZK. The witness could not see the aircraft due to cloud, but noted that it sounded as if it was heading towards the mountains east of Khancoban. The witness said the aircraft sounded like it was much lower than aircraft travelling over the mountains at this point would typically be (9,000 ft AMSL); the witness estimated the aircraft to be travelling at about 4,000 ft AMSL.

The witness observed the weather to be completely overcast. The cloud was low enough to be sitting on nearby hilltops, the peaks of which the witness believed to be between 2,500-3,000 ft AMSL.

Icing conditions

BoM forecasts note that flying in any cloud above the freezing level implies moderate icing conditions. The BoM publication titled Airframe Icing advises pilots on the effects that icing can have on an aircraft. It states that icing can:

• alter the smooth flow of air over the aircraft
• reduce pilot visibility
• produce errors in instrument readings of air speed, altitude and vertical speed
• increase the stall speed by increasing its weight and changing the aerodynamics of the wing and tail 
• increase drag and decrease lift (tests have shown that icing no thicker or rougher than a piece of coarse sandpaper can reduce lift by 30% and increase drag by 40%)
• make it almost impossible to operate control surfaces and landing gear
• reduce thrust or cause engine failure.

Because VH-KZK was fitted with a pitot heat system, and a fuel-injected engine, the most likely adverse outcomes from icing involved ice forming on the exterior parts of the airframe. According to the BoM, this type of icing is caused by water droplets from cloud or precipitation striking the airframe at temperatures below the freezing level.

Operational information

Visual meteorological conditions

Visual meteorological conditions (VMC) are expressed in terms of in-flight visibility and distance from cloud (horizontal and vertical) as prescribed in the Civil Aviation Safety Regulations (CASR) Part 91 General Operating and Flight Rules. The accident flight was conducted entirely in uncontrolled (Class G) airspace. In order for the pilot to conduct such a flight under VFR while remaining below 10,000 ft (in accordance with licence requirements), the following VMC criteria needed to be maintained at all times:

• 5,000 m visibility with 1,000 ft vertical and 1,500 m horizontal distance from cloud
• When below the higher of 3,000 ft AMSL or 1,000 ft AGL and in sight of ground or water, the aircraft may be just clear of cloud. 

These criteria were illustrated in the CASA Visual Flight Rules Guide (Figure 6). Generally speaking, aircraft flying in conditions that do not meet these criteria are in instrument meteorological conditions (IMC). 

Figure 6: Visual meteorological conditions (VMC) criteria below 10,000 ft

Source: Civil Aviation Safety Authority

Flight planning requirements

Flight rules required that pilots study the appropriate authorised weather forecasts and reports in accordance with the CASR Part 91 Manual of Standards. This included authorised weather forecasts and reports for:

• the route to be flown
• the departure aerodrome, the planned destination aerodrome and any planned alternate aerodrome.

Improving the odds

In 2010 the ATSB published Improving the odds: Trends in fatal and non-fatal accidents in private flying operations (AR-2008-045), which found that assessing and planning problems contributed to 46% of fatal accidents involving Australian private flights between 1999 and 2008. The report stated that: 

Assessing and planning issues associated with collision with terrain and/or loss of control accidents mostly involved pilots failing to plan for the weather conditions, not properly assessing the weather during flight, or deciding to continue to fly in marginal weather.

The report provided extensive discussion (pages 16 through 21) on topics including ways of avoiding VFR into IMC accidents, such as through emphasising assessment of flight conditions (particularly weather conditions), evaluating effectiveness of plans, and setting personal minimums.

Spatial disorientation

The ATSB publication Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions (AR-2011-050) discusses the physiological limitations of the human body when trying to sense its orientation in space:

In conditions where visual cues are poor or absent, such as in poor weather, up to 80 per cent of the normal orientation information is missing. Humans are then forced to rely on the remaining 20 per cent, which is split equally between the vestibular system and the somatic system. Both of these senses are prone to powerful illusions and misinterpretation in the absence of visual references, which can quickly become overpowering.

Pilots can rapidly become spatially disoriented when they cannot see the horizon. The brain receives conflicting or ambiguous information from the sensory systems, resulting in a state of confusion that can rapidly lead to incorrect control inputs and resultant loss of aircraft control.

The somatogyral illusion is one possible consequence of spatial disorientation, described in the ATSB publication Visual flight at night accidents: What you can’t see can still hurt you (

):

This illusion relates to a pilot’s incorrect understanding of an aircraft’s angle of bank. When the angle of bank is changed, the pilot’s vestibular system will register any angular acceleration above a threshold level of activation. Once the aircraft is in a constant turn, the pilot’s vestibular system will stop registering any input because there is no angular acceleration. In the absence of any other sensory information or vestibular input a pilot may experience a sensation that the aircraft is no longer turning.

The CASA publication titled Spatial disorientation was published in 2024 as part of the AvSafety program. This detailed several commonly observed illusions that pilots can experience as a result of spatial disorientation. The ‘Graveyard spiral’ described in the publication can occur as a result of the somatogyral illusion:

This can happen when an aircraft begins to bank in cloud or dark night conditions. A constant rate of bank will be undetectable by the vestibular apparatus in a pilot’s head, and unless the pilot is scanning the attitude indicator continuously there will be no visual clue. Rushing slipstream will indicate the increasing airspeed of a dive in what otherwise appears to be straight-and-level flight. Attempts to pull out of the dive often only tighten the unrecognised turn and can cause overstressing and failure of the aircraft structure.

For non-instrument rated pilots, entering IMC can quickly become fatal. Research has shown that pilots not proficient in instrument-only flight will typically become spatially disoriented and lose control of the aircraft within 1–3 minutes after visual cues are lost.

Additional details on spatial disorientation and illusions in low-visibility conditions are provided in the ATSB investigation report VFR flight into dark night involving Aérospatiale AS355F2 (Twin Squirrel), VH-NTV, 145 km north of Marree, South Australia, on 18 August 2011 (AO‑2011‑102).

Related occurrences

Between 2015 and 2025 there were 116 VFR into IMC occurrences in Australian airspace reported to the ATSB. Of these, 13 were fatal accidents resulting in 24 fatalities. Based on these figures, approximately 1 in every 9 reported VFR into IMC occurrences results in a fatality. 

Safety analysis

Spiral descent

The aircraft’s steadily increasing rate of descent and rate of turn in the period leading up to the impact with terrain were consistent with spatial disorientation, specifically, the somatogyral illusion and the ‘graveyard spiral’ described by CASA and others. 

Broken cloud was forecast in the mountains east of Khancoban between 3,000 ft AMSL to above 10,000 ft AMSL. There were also areas of drizzle with overcast conditions between 3,000 ft and 9,000 ft AMSL. The report from the witness near Khancoban airport indicated local conditions consistent with this forecast. Given the terrain elevation in the area, it is therefore almost certain that the aircraft encountered weather conditions making visibility marginal or worse, possibly for extended periods.

The aircraft’s increasing rate of descent and maximum allowable airspeed exceedance just before the collision with terrain indicated that the pilot was either not aware of the aircraft’s speed and attitude, or was not able to correct it during the descent. 

The pilot held a valid basic class 2 medical certificate and there was no available evidence to indicate any medical conditions likely to impact their flying ability, although an incapacitating medical event could not be entirely ruled out.

Prior to the spiral descent, the aircraft maintained a steady altitude and groundspeed, which did not indicate any engine or control issues to that point. An engine issue by itself should also not result in a high-speed, spiralling descent, unless there was also a control issue present. Control issues could not be entirely ruled out, since the wreckage was not examined, and photographs were insufficient to determine aspects such as control cable continuity or the presence of all control surfaces.

Aircraft icing was another possibility. It can affect a number of aspects relating to aircraft performance, handling or pilot visibility, and multiple control surfaces jammed by ice at the same time could result in an uncontrolled spiral flightpath. Structural icing would only be expected if the aircraft was in cloud or precipitation. In either case, based on the forecast, the aircraft would be in IMC where spatial disorientation would also be a concern. 

In either case, the aircraft’s flight path, including what appear to be 2 controlled turns beyond Khancoban, indicates that the aircraft remained controllable until at least the commencement of the spiral. The manoeuvres also indicate that the pilot deliberately left the planned flight route, and were consistent with attempts to navigate around cloud or showers and possibly find a landing area. For example, the first turn might have been an attempt to return to Khancoban or another airport such as Corryong or Wangaratta, and the second turn the result of cloud closing in behind the aircraft, preventing such a return. 

Considering the weather conditions on the day, the pilot’s limited training and experience, and the proven hazard of entering IMC as a VFR pilot, it is therefore very likely that the pilot experienced spatial disorientation in low-visibility conditions, leading to an undetected spiral descent. 

VFR into IMC

Just beyond Khancoban, the weather forecast indicated that broken cloud was expected from ground level (above 3,000 ft AMSL) up to above 10,000 ft AMSL. The vertical extent of the cloud would have made this particularly challenging for the pilot because it was probably not possible to fly above the broken cloud and remain under 10,000 ft in accordance with licence restrictions. 

Because there were no weather stations recording observations near the accident site, the actual weather conditions that the pilot encountered could not be determined beyond a single witness account (at ground level) and a satellite image that shows cloud in the area. While the conditions might have differed from the weather forecast, the forecast conditions indicated that a pilot would have no certainty of maintaining VFR. The pilot was not IFR rated and training records indicated that they had only flown 1 hour of instrument flight training. 

While the pilot had completed some navigation training including a solo navigation flight, they were yet to complete the training syllabus necessary to obtain a navigation endorsement for their recreational pilot licence. As such, they were not authorised to fly the 189 NM distance between Wangaratta and Moruya. Additionally, while the pilot had received training and been assessed as competent at reading weather forecasts in an aviation context, they likely had limited experience in this respect and had not been assessed on some relevant elements required for the PPL such as the more advanced interpretation of forecasts, and determination of alternate or holding requirements. This increased the likelihood of misinterpreting the forecast or underestimating the difficulty of navigating the forecast conditions.

There is limited information available to establish the extent or specifics of the pilot’s pre-flight planning. The exact weather scene presented to the pilot upon entering the mountains was not known, nor was the pilot’s decision-making regarding initiation and continuation of the flight. 

The number of reported VFR into IMC occurrences over the last 10 years indicates that many pilots, some likely with more experience, have found themselves in unsuitable weather situations yet continued the flight. However, studies have shown that pilots who do not accurately perceive the risks of adverse weather are more likely to engage in higher risk activities when dealing with weather (Cooper, 2003). The pilot’s limited training and experience with adverse weather conditions may therefore have contributed to their perception of risk and associated decision-making. 

Findings

From the evidence available, the following findings are made with respect to the VFR into IMC and collision with terrain involving Beechcraft 35-C33 Debonair VH-KZK, 12 km east of Khancoban, New South Wales on 15 July 2025. 

Contributing factors

• The pilot very likely encountered instrument meteorological conditions, resulting in spatial disorientation and collision with terrain.
• The pilot commenced a solo navigation flight, into areas with forecast instrument meteorological conditions, without having completed the required training and licensing for cross-country navigation.

Sources and submissions

Sources of information

The sources of information during the investigation included the:

• Australian Maritime Safety Authority
• Airservices Australia
• Civil Aviation Safety Authority
• New South Wales Police Force
• pilot’s flight instructor
• maintenance organisation for VH-KZK
• witness to the flight
• pilot's next of kin.

References

Australian Transport Safety Bureau. (2011). Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions. Aviation Research Investigation Report AR-2011-050.

Bureau of Meteorology. (2025, June 4). Airframe icing. Australian Government. https://www.bom.gov.au/aviation/data/education/icing.pdf

Cooper D. (2003). Psychology, Risk and Safety: Understanding how personality & perception can influence risk taking. Professional Safety. Journal of the American Society of Safety Engineers, November 2003, 39-46.

Submissions

Under section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. That section allows a person receiving a draft report to make submissions to the ATSB about the draft report. 

A draft of this report was provided to the following directly involved parties:

• Civil Aviation Safety Authority
• Australian Maritime Safety Authority
• Bureau of Meteorology
• the pilot’s flight instructor.

Submissions were received from:

• Civil Aviation Safety Authority
• Bureau of Meteorology
• the pilot’s flight instructor.

The submissions were reviewed and, where considered appropriate, the text of the report was amended accordingly.

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