The Beech 36 aircraft flew over the active drop zone at about 2,000 ft and narrowly missed a parachutist. The aircraft passed underneath the parachute and did not respond to repeated warning calls on radio.
The red parachute symbol on the VTC is in the incorrect place (South of the Warrego highway) and would encourage pilots to track north of the highway, which is where the drop zone is located.
As a result of the investigation and subsequent analysis into this and other related incidents at the same location, the Bureau of Air Safety Investigation issued the following interim recommendation to the Civil Aviation Safety Authority and Airservices Australia on 24 November 1995.
"IR950225
"The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority, in conjunction with Airservices Australia, amend both the Brisbane and Oakey Visual Terminal Charts to display a danger area symbol alerting pilots to the location and hazards presented by parachute operations at the Gatton ALA. As an interim measure during the time required to cover the changes, a NOTAM should be issued alerting pilots to the incorrect location of the parachute symbol."
The following response was received from the Civil Aviation Safety Authority on 18 January 1996.
"I refer to your interim recommendation number IR950225 concerning an incident involving Beech A36, VH-PRI on 8 July 1995.
"The Authority is aware that the operator of the parachute drop zone at Glenore Grove, near Gatton QLD, has submitted a number of incident reports concerning aeroplanes tracking over his ALA whilst following the Warrego Highway between Archerfield and Toowoomba.
"As a result of these reports, the Authority requested Airservices to issue a NOTAM on 27 October 1995 to correct the position of the chart symbol depicting this operation, which is incorrect on the Brisbane VTC but correct on the Oakey VTC (both dated 7 December 1995).
"In discussion with the operator it appears that, despite his making the required broadcasts prior to parachutists exiting the drop aeroplane other traffic in the area are not responding to those broadcasts and therefore parachutists are not aware of traffic which will pass below them whilst they are still under canopy some five minutes later. This traffic may be up to 15 miles from the drop zone at the time the drop aircraft broadcasts its advisory message and may not recognise the potential for confliction.
"A further difficulty is that the drop zone is only four miles from the frequency change point which coincides with the Amberley CTR boundary, and so broadcasts are often made on both frequencies. As an additional precaution, the target control officer on the drop zone monitors traffic on a portable VHF transceiver.
"The operator has previously sought the advice of the Queensland RAPAC on the establishment of a formal danger area to provide an enhanced warning to itinerant aircraft of the extent of the hazard posed by their overflying this area. However, the Authority is not convinced that a danger area is necessary in this case.
"Nevertheless, since airspace is now the responsibility of Airservices Australia, your report and recommendation have been passed to them for consideration.
"The questions of re-issuing a safety poster about parachuting activity and publishing an article on ways to minimise risks when flying near a parachute drop zone, have been raised with the Authority's Safety Promotion Section and some further educational material is under consideration."
The following response was received from Airservices Australia on 6 May 1996.
"Subject: BASI IR950225 Gatton
"Reference incorrect location of parachute symbol;
A NOTAM was issued alerting pilots to the parachute symbol location. The symbol appears on the 20 June 1996 charts at the amended position.
"The proposal for a Danger area was referred to the Queensland Regional Air Co-ordinating Sub Committee (RACS) for consideration.
"As part of the "Process 5 for the Origination, Co-ordination, Ratification, Promulgation and Registration of Airspace and Air route Amendment Proposals " the recommendation was considered by the Queensland Regional Airspace Users Advisory Council (RAPAC).
"The RAPAC did not support the establishment of a Danger area. Further action regarding chart symbols, pilot education and consultation with CASA is to be undertaken by the RACS."
The Bureau of Air Safety Investigation has classified these responses as: CLOSED - PARTIALLY ACCEPTED.