Inexperience ends in tragedy

One of the most dangerous situations a pilot operating under Visual Flight Rules (VFR) could be faced with is the complete loss of visual reference. In the last five years, 28 people have been fatally injured in such circumstances.

VFR flight into IMC

Year Occurrences Accidents Fatalities
1995 38 7 13
1996 34 1 2
1997 33 1 3
1998 39 4 3
1999 36 4 7

On 14 October last year, a VFR pilot with 220 hours flying experience set off from Lightning Ridge for Caloundra in a Cessna 182 in VFR weather. Although the weather forecasts looked reasonable when he took off, by the time he was overhead Goondiwindi the actual weather conditions were not looking good.

Morton Bay to Toowoomba map

At about 1100 the radar controller noticed a secondary surveillance radar return (code 1200), operating in close proximity to the boundary of controlled airspace at about 5,600 feet above mean sea level.

By the time the controller was able to talk to the pilot at 1107:57, the aircraft was inside controlled airspace bearing 310 degrees M from Amberley at 30 NM. The pilot was immediately instructed to make a left orbit to maintain separation from an inbound F111 with an in-flight emergency.

During the orbit, the pilot advised the controller that he was caught in cloud and that he was in trouble. The controller tried to clarify what was happening, and spoke to the pilot a number of times.

By the time the controller had established that the pilot wanted to track to Caloundra and while rated only for VFR flight was now non-visual, the pilot had commenced a second left orbit. Half way through the orbit, passing a heading of approximately 240 degrees, the controller instructed the pilot to turn right and take up a northerly heading for Caloundra.

While in the right turn, the controller asked the pilot if he wanted to descend. The pilot replied yes and he was cleared to leave control area on descent.

The aircraft's altitude during the turn was erratic. It descended to 4,400 feet in less than a minute then climbed back to 4,800 feet. The pilot continued the right turn onto a heading of about 130 degrees then began a left turn to intercept the track from Toowoomba to Caloundra.

While the pilot was doing this, the controller told him that he could descend safely to 3,000 feet in the aircraft's current location. Once established on track to Caloundra, the aircraft maintained a steady heading with a rate of descent of about 300 feet per minute.

Esk map identifies accident site

The controller then instructed the pilot to turn right heading 130 degrees, a turn of about 90 degrees, to avoid an area of higher terrain where the radars lowest safe altitude was 3,800 feet. The aircraft was passing through 3,700 feet when the turn began.

The aircraft continued to turn through the assigned heading and its ground speed and rate of descent increased. Its radar return disappeared from the radar display at about 1116 as it was passing through 3,200 feet on a heading of approximately 210 degrees.

The pilot's last broadcast was at about 1116 in response to a question from the controller.

The wreckage of the aircraft was located about 6.5km north of Esk on flat pastoral land. A nearby resident had called the emergency services at 1117:30 after he had observed a plume of fuel and debris.

The aircraft was in a left spiral dive when it impacted the ground. The weather was showery and cloud covered the tops of the hills. The aircraft was destroyed.

Some safety lessons

Air Traffic Services (ATS) emergency procedures are outlined in chapter 17 of the Manual of Air Traffic Services (MATS), which is a joint military/civil document. It covers the declaration of emergency phases and outlines procedures for handling in-flight emergencies, including situations involving flight confined to Visual Meteorological Conditions (VMC) but operating in Instrument Meteorological Conditions (IMC).

Accident site

According to MATS, a pilot faced with this situation would have difficulty maintaining headings and altitude and perceiving aircraft attitude. ATS should try to reassure the pilot and limit communications to avoid diverting the pilot's attention from flying the aircraft.

Airservices Australia's In-flight Emergency Response (IFER) Training Manual gives more detailed guidance for handling a VFR in IMC situation. This manual advises Air Traffic Controllers to help an inexperienced pilot in distress with some reminders on aircraft handling such as concentrating on aircraft attitude (steady heading, wings level, constant speed); trusting what the instruments say; and when manoeuvring make gentle movements (climb, turns, descents) and to turn first then establish straig

ht and level before climb or descent.

Controllers could also help a pilot by giving navigational information that would help to re-establish the aircraft in VMC. In communicating with the pilot, controllers should keep instructions simple and distractions to a minimum, while also instilling confidence and providing reassurance. It is also important to pass only one item at a time.

According to the IFER manual, communication style is important. It states that a VFR pilot in an IMC situation is under considerable stress and there is a need for ATS staff to convey empathy, patience and confidence. This would require staff to adopt a different technique to the customary delivery of information. It was vital that questions were not put in an interrogative manner.

The ATSB found that there was no record that the Australian Defence Force (ADF) had received copies of the IFER training manual from Airservices, and it, or an ADF equivalent, was not held at any ADF ATS unit. However, ADF units did hold copies of the Airservices IFER checklist, a document separate from the IFER training manual.

Accident aircraftAccording to the ATSB's investigation the controller communicated with the pilot in an authoritative manner and questions were posed in an interrogative style. ATS staff referred to the IFER checklist, but were unaware of the more detailed guidance contained in the training manual.


As a result of concerns regarding military air traffic control officers' awareness of in-flight emergency response practices and procedures for civil aircraft, the Bureau issued interim recommendation IR 19990190 to the Australian Defence Force on 16 December 1999. The ATSB recommended that the ADF review IFER training for air traffic services staff responsible for the provision of services to civil aircraft.

As a result, the ADF undertook a comprehensive review of IFER training, procedures and practices. The review concluded that Defence IFER management and training was capable of improvements and the Chief of Air Force directed that 11 recommendations arising from the review be implemented by 30 June 2000. The recommendations included enhancements to abinitio and post-graduate IFER training, establishment of dedicated training officer positions within ATC flights and development of a formal Supervisors course, incorporating IFER and team/crew resource management instruction.

Despite the ATS issues that came to light after this tragic accident, the pilot flew on into IMC, a situation that was beyond his skills and experience. It is likely that he became spatially disoriented and lost control of the aircraft soon after descending through 3,200 feet.

Type: Educational Fact Sheet
Publication date: 20 July 2000
Last update 07 April 2014