Aviation safety investigations & reports

Controlled flight into terrain involving Mooney M20J, VH-DJU, 26 km west of Coffs Harbour Airport, New South Wales, on 20 September 2019

Investigation number:
AO-2019-052
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final report
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What happened

At about 0640 Eastern Standard Time on 20 September 2019, a Mooney M20J aircraft, registered VH-DJU, departed Murwillumbah, New South Wales for a private flight under visual flight rules to Taree, New South Wales. On board were the pilot and one passenger.

At 0717, when DJU was 45 NM north of Coffs Harbour, the pilot contacted air traffic control and requested a clearance to transit the Class C controlled airspace at 6,500 ft. Air traffic control advised that a clearance was not available at that altitude and that, due to cloud conditions, a visual transit of the airspace would only be possible at an altitude not above 1,000 ft. The pilot then advised that the flight would descend to ‘not above 1,000 ft’.

The aircraft continued on a direct track to Taree and at 0724 the pilot reported that the aircraft was operating outside controlled airspace in clear conditions at 4,100 ft and would remain on that track. The aircraft was then climbed to 4,500 ft and at 0732, commenced a descent in the vicinity of high terrain.

The aircraft did not arrive at Taree as expected so a search was initiated. The aircraft was found to have collided with terrain about 26 km west of Coffs Harbour Airport. The two persons on board were fatally injured and the aircraft was destroyed.

What the ATSB found

The ATSB found that the pilot was not provided clearance to transit Class C airspace due to the trainee controller’s conservative assessment that workload would not allow it although there was no conflicting traffic, meteorological factor or limiting air traffic control instructions or procedures. The trainee’s supervisor accepted the assessment as an alternate transit option was provided to the pilot. Additionally, the information subsequently provided by air traffic control likely resulted in the pilot deciding to descend the aircraft from 6,500 ft instead of other available safe options. This descent exposed the flight to increased risk.

The ATSB also found that the pilot was not carrying suitable navigation equipment and had most likely not obtained the required weather forecasts. These factors reduced the pilot's ability to manage the flight path changes and identify the high terrain. This led to the aircraft being descended toward the high terrain in visibility conditions below that required for visual flight, resulting in controlled flight into terrain.

The pilot had also not completed the required flight reviews or proficiency checks. This resulted in the pilot not possessing the required licence to undertake the flight and likely led to a deterioration in the knowledge and skills required for effective flight management and decision‑making.

What has been done as a result

Following the occurrence, Airservices Australia (Airservices) provided additional training for air traffic controllers focussing on clearance issues, workload assessments, and coordination with other traffic units where decisions affect the other unit. An information and education package was developed for controllers regarding the provision of advice and information to pilots not subject to a clearance.

Performance checks and unit reviews were also undertaken to provide assurance that airways clearances were consistently issued in accordance with documented procedures. Airservices also included additional content in on‑the‑job instructor professional development sessions to ensure trainees’ capability is commensurate with actual workload to optimise performance.

Safety message

The safety risks of visual pilots flying into non-visual conditions are well documented. This continues to be a recurring factor in aircraft accidents and has been the focus of numerous previous ATSB reports and publications.

This accident also emphasises the importance of pilot and flight preparation. Ensuring that all required training is completed assists a pilot to both develop and maintain the necessary skills to manage challenges that may be encountered during a flight, such as inclement weather or inadvertent entry into non-visual conditions. Further, confirming that appropriate operational information is obtained and readily available ensures that a pilot is well prepared to anticipate in‑flight complications and successfully manage unforeseen challenges.

The accident also illustrates the significant influence that air traffic control can have on the conduct of a flight.

Download Final report
[Download  PDF: 2.62MB]
 
 
 

The Occurrence

Context

Safety analysis

Findings

Safety action

General details
Date: 20 September 2019   Investigation status: Completed  
Time: 0734 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 26 km west of Coffs Harbour Airport,   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Collision with terrain  
Release date: 19 January 2021   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Mooney Aircraft Corp  
Aircraft model M20J  
Aircraft registration VH-DJU  
Serial number 24-1075  
Operator Private  
Type of operation Private  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Murwillumbah, NSW  
Destination Taree, NSW  
Last update 28 January 2021