Investigation number
Occurrence date
Scone Aerodrome
New South Wales
Report release date
Report status
Investigation level
Investigation type
Occurrence Investigation
Investigation status
Aviation occurrence type
Collision with terrain
Occurrence category
Highest injury level

ATSB response to the Coroner

The ATSB notes that NSW Deputy State Coroner, Sharon Freund has recently released a finding into a fatal accident involving aircraft registered VH-EKS.  The ATSB was not required to give evidence, however the report of the ATSB was utilized by the Coroner for the purpose of her findings.  The Coroner’s findings were substantially in accordance with the ATSB investigation.

Circumstances of the accident

At about 1452 Eastern Daylight-saving Time on 24 December 2008, a Cessna Aircraft Company 172L aircraft, registered VH-EKS, with a pilot and one passenger, departed Mudgee on a private visual flight rules (VFR) flight to a property near Glen Innes, New South Wales. About 15 minutes after departure, the pilot encountered increasing cloud and, after climbing to assess the weather ahead, decided to descend visually through the cloud in order to maintain visual meteorological conditions.

The pilot descended the aircraft into a valley that was enshrouded in cloud. After flying up the valley for a short time, the pilot decided to turn back. During the turn-back manoeuvre, the aircraft entered cloud. The pilot became disorientated and the aircraft collided with terrain.

The pilot and passenger were seriously injured and the aircraft was seriously damaged. Shortly after, the passenger succumbed to his injuries.

ATSB Findings

The ATSB made the following findings:

Contributing safety factors

  • The pilot chose not to obtain the relevant aviation weather forecasts for the flight.
  • The pilot chose not to turn back or divert, after climbing to 7,500ft and identifying deteriorating weather ahead.
  • The weather conditions were such that there was an increased risk of the pilot being unable to continue the flight in visual meteorological conditions.
  • The pilot flew into instrument meteorological conditions, in which he was not qualified to operate.
  • The pilot became disoriented, reducing the likelihood of a successful turn back and precipitating the collision with terrain.

Other safety factors

  • The pilot did not fully plan the flight in accordance with the flight planning requirements, specifically with respect to fuel planning.
  • The current advice in Civil Aviation Advisory Publication 5.81-1(0) Flight Crew Licensing Flight Reviews in relation to the assessment of navigation skills, represents a missed opportunity to identify a pilot’s capacity to make safe and appropriate decisions during cross-country flying. [Minor safety issue]
  • The flight planning requirements at page 88 of the Visual Flight Guide included a transcription error that inadvertently limited the application of the requirements of Civil Aviation Regulation 239. [Minor safety issue]

Other key findings

  • The pilot's decisions not to submit any form of flight notification and not to replace the aircraft's emergency locator transmitter contributed to the delay and confusion in mounting an expeditious search and rescue.

Safety action

In respect of CAAP 5.81-1(0) and page 88 of the Visual Flight Guide, the Civil Aviation Safety Authority (CASA) took action to amend the CAAP and withdrew the Visual Flight Guide for amendment.

CASA’s response to the safety issues may be found at Safety Issues

ATSB investigations and coronial investigations

Coronial investigations are separate to ATSB investigations. In this matter the respective authorities are largely in accord as to the factors that contributed to the development of the accident involving VH-POJ.

The ATSB's report can be downloaded by clicking on the link: Final Report

The Coroner's report can be obtained from the Coroner's Court of NSW Contact details are available at: Queries regarding the Coroner's findings should be directed to the Coroner's Court of NSW.


Aircraft Details
Departure point
Mudgee, NSW
Glen Innes, NSW
Serial number
Operation type
Cessna Aircraft Company