Preliminary report published 23 April 2020
The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this update. As such, no analysis or findings are included in this report.
On 19 February 2020, at about 1055 Eastern Daylight-saving Time, a Beech Travel Air D95A aircraft, registered VH-AEM (AEM), departed Tyabb Airport, Victoria for an Instrument Flight Rules (IFR) training flight to Shepparton via Mangalore, and return to Tyabb. On board were an instructor and student.
At 1111, the pilot of a Piper PA44-180 Seminole, registered VH-JQF (JQF) contacted air traffic control (ATC) to advise that the aircraft was taxiing for departure from Mangalore Airport. The pilot had submitted a flight plan for a round-trip IFR flight for Mangalore via Essendon and Shepparton. Also on board was an authorised testing officer, who was testing the pilot for an instrument flight rating.
AEM tracked as per the flight plan and, at 1117, began a descent from 6,000 ft above mean sea level (AMSL) for airwork at Mangalore. Radio communication with ATC indicated the airwork was to occur between 4,000 ft and ground level.
At 1119, the air traffic controller passed traffic information to AEM about JQF departing from Mangalore. At 1122, JQF made a departure call from Mangalore, advising ATC of a planned climb to 7,000 ft. ATC passed traffic information about AEM to the Seminole crew.
At 1124, Automatic Dependent Surveillance Broadcast (ADS-B) data indicated the two aircraft collided approximately 8 km south of Mangalore Airport at approximately 4,100 ft (Figure 1). There were no witnesses to the collision, however another pilot in the area witnessed both aircraft descending immediately after the collision. All four pilots were fatally injured in the accident, and both aircraft were destroyed.
Source: Google, modified by the ATSB
All four pilots involved in the accident held the licences and medical approvals required to undertake the operations they were conducting.
The instructor on board AEM held an air transport pilot licence (aeroplane) and was a grade 1 flight instructor, with approvals to conduct instrument rating instruction and multi-engine aircraft class rating instruction. The instructor’s logbook indicated he had about 5,800 hours total flying experience. The student on this aircraft held a commercial pilot licence (aeroplane), and had passed the instrument rating theory exam. The student’s logbook indicated he had approximately 1,100 flight hours. This lesson was his second instrument training flight.
The examiner on board JQF held an air transport pilot licence (aeroplane), was a grade 1 flight instructor, and held a flight examiner rating to conduct a range of examinations, including for instrument ratings and multi-engine class ratings. He had about 21,000 hours flying experience. The pilot on this aircraft held a commercial licence (aeroplane), and had passed the instrument rating theory exam. This pilot’s logbook indicated she had approximately 220 hours of total flight experience. The test being conducted was for the purpose of issuing the pilot with both an instrument rating, and a multi-engine class rating.
VH-AEM (Figure 2) was a Beech D95A Travel Air, twin-engine aircraft. It was manufactured in the United States of America in 1966 with serial number TD-682. It was first registered in Australia in 1967.
Source: Aircraft operator
VH-JQF (Figure 3) was a Piper PA44-180 Seminole, twin-engine aircraft. It was manufactured in the United States of America in 1979 with serial number 44-7995291. It was first registered in Australia in 1990.
Source: Aircraft operator
Wreckage and impact information
Following the mid-air collision, JQF travelled for about 0.5 km before impacting an open field, while AEM continued in a northerly direction and impacted a lightly wooded area about 1.4 km from the collision point. Airborne debris liberated in the collision formed a further wreckage field that was located about 1.6 km to the north-north-east of the collision point and about 200m to the west of the Hume Highway.
The forecast meteorological conditions for the Mangalore area indicated scattered cloud at 2,000 ft above ground level (approximately 2,500 ft above mean sea level), with scattered stratocumulus cloud between 3,000 and 6,000 ft. Visibility was forecast to be greater than 10 km, and the wind from the south‑west at 25 knots.
At the time of the accident, the automatic weather station at Mangalore Airport, 8 km north of the collision location, recorded two cloud layers: one scattered at 3,467 ft AMSL and a second broken layer at 4,174 ft AMSL, (about the collision altitude).
Video taken by the Victoria Police Air wing (Figure 4) near the accident site at 1240, 1 hour and 16 minutes after the accident showed the base of a broken layer of cloud to be at approximately 4,050 ft AMSL with some lower patches of cloud also present.
Source: Victoria Police
Aerodrome and airspace information
Mangalore Airport has an elevation of 467 ft. The airport was non‑controlled, and utilised a ‘Common Traffic Advisory Frequency’ (CTAF). The CTAF frequency was shared with three other aerodromes in the local area.
Surrounding the Mangalore CTAF was class G non‑controlled airspace. In class G airspace, air traffic controllers provide traffic information to IFR aircraft about other conflicting IFR and observed VFR flights.
Neither aircraft was equipped with a flight data recorder or cockpit voice recorder, nor were they required to be. One aircraft was carrying an iPad, which had AvPlan software installed and operating at the time of the accident. This data was provided to the ATSB.
Both aircraft were fitted with transponders that broadcast ADS-B data. This information included the position and altitude of the aircraft and was received by Airservices Australia, as well as other third-party ADS-B receivers (FlightRadar24) and provided to the ATSB.
Radio transmissions on the CTAF were not recorded.
The investigation is continuing and will include further examination and analysis of:
- weather conditions at the time of the accident
- recovered radios from the aircraft
- recorded radar data, as well as recorded area frequency calls and recollections of CTAF radio broadcasts.
- pilot qualifications, experience and medical histories
- aircraft maintenance and operational records
- air traffic services actions, procedures and practices
- traffic density in and around Mangalore Airport
- classification of the airspace around Mangalore Airport
- Class G and CTAF operational and communication processes and procedures around Mangalore Airport
- visibility from both aircraft.
Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.
A final report will be released at the conclusion of the investigation.
The ATSB acknowledges the assistance of Victoria Police, and the Victorian Coronial Support Unit in supporting the ATSB’s on-site investigation team, and providing information and support through the evidence collection phase of the investigation.
- Eastern Daylight-saving Time (EDT): Coordinated Universal Time (UTC) +11 hours
- Instrument flight rules (IFR): a set of regulations that permit the pilot to operate an aircraft in instrument meteorological conditions (IMC), which have much lower weather minimums than visual flight rules (VFR). Procedures and training are significantly more complex as a pilot must demonstrate competency in IMC conditions while controlling the aircraft solely by reference to instruments. IFR-capable aircraft have greater equipment and maintenance requirements.
- Automatic Dependent Surveillance Broadcast (ADS-B): A means by which aircraft can automatically transmit or receive data such as identification, position and additional data, as appropriate, in a broadcast mode via a data link.
- Cloud cover: in aviation, cloud cover is reporting using words that denote the extent of the cover – ‘few’ indicates that up to a quarter of the sky is covered, ‘scattered’ indicates the cloud is covering between and quarter and a half of the sky, ‘broken’ indicates that more than half to almost all of the sky is covered, and ‘overcast’ indicates that all the sky is covered.
- Common Traffic Advisory Frequency (CTAF): A designated frequency on which pilots make positional broadcasts when operating in the vicinity of a non-controlled aerodrome or within a Broadcast Area.
- AvPlan is an electronic flight bag application.
|Date:||19 February 2020||Investigation status:||Active|
|Time:||11:24 AEDT||Investigation level:||Defined - click for an explanation of investigation levels|
|Location:||8 km south of Mangalore Airport||Investigation phase:||Examination and analysis|
|State:||Victoria||Occurrence type:||Airborne collision|
|Release date:||23 April 2020||Occurrence category:||Accident|
|Report status:||Preliminary||Highest injury level:||Fatal|
|Anticipated completion:||2nd Quarter 2021|
Aircraft 1 details
|Aircraft manufacturer||Piper Aircraft Corp|
|Aircraft model||PA-44-180 Seminole|
|Operator||Moorabbin Aviation Services|
|Type of operation||Flying Training|
|Damage to aircraft||Destroyed|
|Departure point||Mangalore, Victoria|
Aircraft 2 details
|Aircraft manufacturer||Beech Aircraft Corp|
|Aircraft model||Beech D95A Travel Air|
|Type of operation||Flying Training|
|Damage to aircraft||Destroyed|
|Departure point||Tyabb, Victoria|