Aviation safety investigations & reports

VFR into IMC and loss of control involving Cessna 172, VH-FYN, 13 km NNW of Ballina, NSW, on 16 June 2017

Investigation number:
AO-2017-061
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 16 June 2017, a Cessna Aircraft Company C172M, registered VH-FYN, was being operated on a private flight from Southport Mason Field, Queensland to Ballina Airport, New South Wales. The purpose of the flight was to ferry the aircraft to Ballina for scheduled maintenance. En route, near the town of Bangalow NSW, the aircraft entered an area of reduced visibility, including low cloud, fog and drizzle. The aircraft diverted off the initial track and was last seen disappearing into cloud heading inland. A short time later the aircraft collided with terrain and the pilot was fatally injured.

What the ATSB found

The ATSB found that the decision to depart Southport for Ballina on the morning of 16 June placed the pilot at risk of encountering conditions of reduced visibility. En route to Ballina, the aircraft entered an area of reduced visibility and the pilot likely became spatially disorientated resulting in a loss of control and collision with terrain. It was also found that after re-scheduling his maintenance booking twice, and with the aircraft’s maintenance release due to expire, the pilot was likely under some degree of self-imposed pressure to continue with the flight despite encountering inclement weather conditions. It could not be determined if the pilot consulted the most current weather forecasts on the morning of the accident.

Safety message

Weather-related accidents remain one of the most significant causes of fatal accidents in general aviation and continues to be a focus of the ATSB’s SafetyWatch initiative. SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns relates to inflight decision making, particularly involving pilots flying with reduced visual reference. SafetyWatch provides information about each safety concern, and strategies to help manage risk areas, along with links to safety resources. In relation to visual flight rules (VFR) pilots flying into areas of reduced visibility, some key messages are:

  • Pilots should avoid deteriorating weather by conducting thorough pre-flight planning. They should ensure they have alternate plans in case of an unexpected deterioration in the weather and make timely decisions to turn back, divert or hold in an area of good weather.
  • VFR pilots should use a ‘personal minimums’ checklist to help control and manage flight risks through identifying risk factors that include marginal weather conditions and only fly in environments that do not exceed their capabilities.
  • Pressing on into instrument meteorological conditions without a current instrument rating carries a significant risk of severe spatial disorientation due to powerful and misleading orientation sensations with reduced visual cues. Disorientation can affect any pilot, no matter what their level of experience.
  • If VFR pilots find themselves in marginal weather and becoming disoriented or lost, they should seek whatever help is available. Air Traffic Services (ATS) may be able to provide assistance, especially if the aircraft is in ATS surveillance coverage. There have been a number of reported occurrences where this simple action has averted potential disaster.
Download final report
[Download  PDF: 2.66MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Sources and submissions

General details
Date: 16 June 2017   Investigation status: Completed  
Time: 0850 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Brooklet, 13 km NNW of Ballina   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Collision with terrain  
Release date: 14 March 2019   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 172M  
Aircraft registration VH-FYN  
Serial number 17267270  
Operator Owner  
Type of operation Private  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Southport Mason Field, Qld  
Destination Ballina/Byron Gateway, NSW  
Last update 14 March 2019