Aviation safety investigations & reports

VFR into IMC and loss of control involving Wittman Tailwind, VH-TWQ, Tooloom National Park, New South Wales, on 12 January 2020

Investigation number:
AO-2020-004
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final report

Download Final Report
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What happened

On the afternoon of 12 January 2020, the pilot of an amateur-built Wittman Tailwind aircraft, registered VH-TWQ (TWQ), departed Evans Head Airport, New South Wales, with one passenger on board. The pilot was conducting a private flight under the visual flight rules from Evans Head, to Boonah, Queensland.

The pilot flew in a north-north-westerly direction towards Boonah via the Richmond River valley. At 1353, the pilot commenced a 180° turn overhead the township of Kyogle and diverted, due to the weather, south back down the valley to Casino Aerodrome, landing at 1406.

At 1454, the pilot took off from Casino and flew in a west-north-westerly direction. At 1512 TWQ commenced a series of rapid descents and climbs followed by a descending left turn. The turn and descent continued until TWQ collided with terrain. The pilot and passenger were fatally injured, and the aircraft was destroyed.

What the ATSB found

The ATSB found that the pilot departed an interim landing site for Boonah under the visual flight rules with a high risk of encountering forecast cloud. En route to Boonah, 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.

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.
  • Pilot’s should consider reducing speed and/or altering the configuration of the aircraft to allow more time for decision making and maneuvering in areas of deteriorating or marginal weather conditions
  • 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: 2.06MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Sources and submissions

General details
Date: 12 January 2020   Investigation status: Completed  
Time: 14:53 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Tooloom National Park, 53 km ENE from Stanthorpe   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: VFR into IMC  
Release date: 02 March 2021   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Amateur Built Aircraft  
Aircraft model Wittman Tailwind W10  
Aircraft registration VH-TWQ  
Serial number 05-1305  
Type of operation Private  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Casino, New South Wales  
Destination Boonah, Queensland  
Last update 02 March 2021