Aviation safety investigations & reports

Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF and Beech D95A Travel Air, VH-AEM 8 km south of Mangalore Airport, Victoria on 19 February 2020

Investigation number:
AO-2020-012
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

Around midday on 19 February 2020 a Beech D95A Travel Air, registered VH-AEM, and a Piper PA44-180 Seminole, VH-JQF, collided mid-air approximately 8 km south of Mangalore Airport, Victoria. The Travel Air was approaching Mangalore Airport from the south, on descent to conduct a practice instrument approach, while the Seminole was southbound on climb from Mangalore to Essendon Airport.

Both aircraft were operating under the instrument flight rules (IFR) in non-controlled airspace. The pilots of each aircraft had been provided with traffic information about the other aircraft prior to the collision, in accordance with procedures. Both aircraft were fitted with dual radios. Other pilots monitoring the common traffic advisory frequency (CTAF) associated with Mangalore Airport reported hearing pilots from both aircraft broadcast but had no recollection of hearing them speaking directly to each other.

The two aircraft collided with no evasive manoeuvring identified in recorded flight data. All four pilots were fatally injured and both aircraft were destroyed.

What the ATSB found

This was the first mid‑air collision between two civil aircraft operating under the instrument flight rules and procedures that have been in place in Australia for decades.

The ATSB identified that, following receipt of verbal traffic information from the controller, the pilots did not successfully manoeuvre or establish direct communications on the CTAF to maintain separation, probably due to the collision risk not being recognised.

While it is probable that the aircraft were in instrument meteorological conditions at the time of the collision due to the presence of extensive cloud, the known limitations of the ‘see-and-avoid’ principle meant that the pilots were unlikely to have seen each other in sufficient time to prevent the collision even in clear weather conditions.

Additionally, following receipt of an alert indicating the developing proximity of the aircraft, the controller assessed it in accordance with the required procedure. However, after considering that the pilots were aware of each other’s presence and were required to ensure their own separation in non‑controlled airspace, the controller did not intervene further.

While the pilots were responsible for self-separation within the Mangalore CTAF area, they did not have access to radar or automatic dependent surveillance broadcast (ADS-B) information. As a result, the pilots were required to make timely decisions to avoid a collision without the best available information.

Finally, although not contributory to the accident, the ATSB identified that the wording of procedures relating to the conduct of practice instrument approaches at Mangalore Airport resulted in varied application and an increased risk of traffic conflicts.

What has been done as a result

Airservices Australia (Airservices) have proposed a change to the Civil Aviation Safety Authority (CASA) to introduce a surveillance flight information service (SFIS) around Mangalore Airport, designed to provide enhanced traffic information services to all aircraft operating in a 20 NM radius of the airport. The proposed service would require all aircraft to broadcast on the CTAF within the broadcast area, while providing a dedicated air traffic controller operating on the CTAF to provide a flight information service utilising surveillance.

By listening on the CTAF, the controller would be able to determine whether aircraft have arranged their own separation following receipt of traffic information and provide updated traffic information if required. A similar service was introduced around Ballina Airport in August 2021.

In September 2021, the CASA Office of Airspace Regulation (OAR) announced an aeronautical study into the airspace within a 25 NM area of Mangalore Airport, up to an altitude of 8,500 ft. The scope of this study involves:

  • a review of traffic type and density over the previous 5 years
  • an evaluation of the suitability and efficiency of the airspace
  • a review of the equitability of access to the airspace, the appropriateness of the airspace classification and the suitability of the existing services and facilities provided by Airservices Australia.

As of February 2022 this aeronautical study has not been published.

The proposal for the introduction of an SFIS on the Mangalore CTAF is currently on hold pending completion of the OAR review. However, a dedicated controller is providing safety alerting on the Mangalore CTAF in the interim period. Communications on the CTAF are recorded by Airservices when the safety alerting service is operational. A further consultation has been raised by Airservices to lower the base of Class E airspace around Mangalore Airport. As of February 2022 that proposal was in review by Airservices following an industry consultation period.

In December 2021, the Department of Infrastructure announced a $30 million fund to provide rebates to general aviation aircraft operators to fund up to $5,000 or 50% of the cost of installing ADS-B transponder technology into their aircraft.

Safety message

While this accident involved aircraft operating under the IFR, irrespective of whether operating under the instrument or visual flight rules, pilots are responsible for separation from other aircraft in non‑controlled airspace.

As such, if made aware of traffic, either via advice from air traffic control (ATC), a received broadcast or any other means it is vitally important that the traffic is risk assessed and, if necessary, a plan established to assure separation. The following separation methods can be useful in maintaining a safe operating distance between aircraft:

  • different operating altitudes
  • ground feature reference (e.g. townships, lakes or linear features – rivers, roads)
  • navigation or avionics reference (e.g. radial or GPS distance)
  • ‘clock code’ reference – useful to assist aircraft sighting.

The ATSB also strongly encourages the fitment of ADS‑B transmitting, receiving and display devices as they significantly assist the identification and avoidance of conflicting traffic. The continuous positional information that ADS‑B provides can highlight a developing situation many minutes before it becomes hazardous – a significant improvement on both point‑in‑time radio traffic advice and ‘see‑and‑avoid’. The ATSB also notes that ADS‑B receivers, suitable for use on aircraft operating under both the instrument or visual flight rules, are currently available within Australia at low cost and can be used in aircraft without any additional regulatory approval or expense.

It is also important to recognise however that ADS‑B cannot be relied upon to display all nearby traffic so effective use of radio remains a primary defence in avoiding mid‑air collisions. In that context pilots need to make all required broadcasts detailed in the Aeronautical Information Publication, even if there is no known traffic, and respond to broadcasts if a potential traffic conflict is identified.

The ATSB publication A pilot’s guide to staying safe in the vicinity of non-towered aerodromes highlights some of the known challenges presented to pilots operating around these airfields.

Finally, in line with the key objective of ATC being the prevention of collisions, controllers should advise pilots if they become aware of a developing traffic conflict rather than assume that the pilots are already aware of it.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Glossary

Sources and submissions

Appendix

Update

Investigation progress update published 24 February 2021

The investigation into the mid-air collision involving Piper PA-44-180 Seminole VH-JQF and Beech D95A Travel Air VH-AEM near Mangalore, Victoria, on 19 February 2020, is continuing.

The investigation is currently in the ‘Examination and analysis’ phase. During this phase, evidence is reviewed and evaluated to determine its relevance, credibility and relationship to other evidence and to the occurrence.

ATSB investigators have so far gathered and analysed numerous information sources including:

  • on-site aircraft examination at the two sites where the aircraft were located
  • witness statements
  • weather observations and forecasts
  • recorded flight data
  • aircraft component inspection
  • operational and maintenance documents
  • personnel licence and medical records

Further analysis is occurring on:

  • airspace and air traffic control procedures
  • visibility from both aircraft

Preliminary Report

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.

The occurrence

On 19 February 2020, at about 1055 Eastern Daylight-saving Time[1], a Beech Travel Air D95A aircraft, registered VH-AEM (AEM), departed Tyabb Airport, Victoria for an Instrument Flight Rules (IFR)[2] 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)[3] 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.

Figure 1: Flight path of AEM and JQF, and location of ground impact of both aircraft

Figure 1: Flight path of AEM and JQF, and location of ground impact of both aircraft.
Source: Google, modified by the ATSB

Source: Google, modified by the ATSB

Context

Pilot information

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.

Aircraft information

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.

Figure 2: Beech Travel Air, registered VH-AEM

Figure 2: Beech Travel Air, registered VH-AEM.
Source: Aircraft operator

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.

Figure 3: Piper Seminole, registered VH-JQF

Figure 3: Piper Seminole, registered VH-JQF.
Source: Aircraft operator

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.

Meteorological information

The forecast meteorological conditions for the Mangalore area indicated scattered[4] 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.

Figure 4: View of cloud from the Victoria Police Air Wing helicopter

Figure 4: View of cloud from the Victoria Police Air Wing helicopter. Source Victoria Police

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)[5]. 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.

Recorded data

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[6] 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.

Further investigation

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.

Acknowledgements

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.

__________

  1. Eastern Daylight-saving Time (EDT): Coordinated Universal Time (UTC) +11 hours
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. AvPlan is an electronic flight bag application.

Safety Issue

Go to AO-2020-012-SI-01 -

ERSA procedure

The En-Route Supplement Australia included a requirement to add 1,000 ft to the prescribed practice instrument approach ‘altitude’ at Mangalore Airport. The procedure did not detail whether this height was to be applied to the minimum descent altitude or to all approach altitudes, resulting in varied application and an increased risk of traffic conflicts. (Safety issue).

Safety issue details
Issue number: AO-2020-012-SI-01
Status: Open – Safety action pending
General details
Date: 19 February 2020   Investigation status: Completed  
Time: 1124 EDT   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Mangalore Airport, Victoria   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Airborne collision  
Release date: 31 March 2022   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 95  
Aircraft registration VH-AEM  
Serial number TD-682  
Operator Peninsula Aero Club  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Tyabb, Victoria  
Destination Mangalore, Victoria  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-44  
Aircraft registration VH-JQF  
Serial number 44-7995291  
Operator Moorabbin Aviation Services  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Mangalore, Victoria  
Destination Mangalore, Victoria  
Last update 31 March 2022