Aviation safety investigations & reports

VFR into IMC involving a Piper PA-28, VH-FPS, near Warrnambool, Victoria on 25 February 2021

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

Final report

Download Final report
[Download  PDF: 661KB]

What happened

On 25 February 2021, a Piper Aircraft PA-28, registered VH-FPS, operated by Moorabbin Aviation Services, departed Warrnambool Airport for Moorabbin Airport, Victoria. The flight crew were conducting a training flight under the visual flight rules (VFR). There was an instructor, student pilot and a passenger on board.

During the cruise, the weather deteriorated and the aircraft was returned to Warrnambool. As the aircraft approached Warrnambool, the visibility reduced and the instructor initiated a climb into cloud. They contacted air traffic control and received navigation assistance to an area free from cloud. The flight then proceeded to Moorabbin Airport where the aircraft landed safely.

What the ATSB found

The ATSB found that although the flight crew had conducted a pre-flight briefing, they did not detect the forecast deteriorating weather in the Warrnambool area. In addition, they did not assess the aerodrome forecast for both Moorabbin and Warrnambool to ensure they were suitable destination airports. The aircraft departed Warrnambool in visual flight conditions however, as forecast, the weather subsequently deteriorated and the flight crew initiated a return to Warrnambool. During the return, the conditions reduced below that required for visual flight resulting in the VFR certified aircraft entering instrument meteorological conditions (IMC).

After entering IMC, the pilot requested assistance from the controller and maintained control of the aircraft.

What has been done as a result

As a result of this occurrence, the operator advised that they have developed a:

  • weather information board, which displays the synoptic charts, relevant TAFs and grid point wind and temperature charts for the day at the Moorabbin base.
  • Warrnambool PowerPoint presentation for dual and solo flight exercises, to emphasis the prevailing weather in that region of Victoria and Bass Strait.
  • supervision policy in the Training Management Manual to facilitate varying supervision based on the experience level and proven competency of the junior instructors and other circumstances which may challenge the junior instructor’s skill set.
  • company policy to provide organisational support for flight crew required to stay away from base overnight due to adverse weather, aircraft unserviceability or pilot incapacity/fatigue, including arrangement and payment of transport and accommodation if required. This policy will be promoted through both staff and student levels.
  • program on effective decision making to be delivered to all staff.

Safety message

Weather related incidents continue to be a significant concern in aviation safety. As stated in the ATSB publication Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions,1 in 10 VFR into IMC events result in a fatal outcome. This report highlights that ‘thorough pre-flight preparation is the best defence against flying into deteriorating weather’.

The ATSB encourages pilots, of all experience levels, to develop the knowledge and skills required to avoid unintentional operations in IMC. However, if a VFR‑rated pilot does find themselves in marginal weather, they should seek whatever assistance is available, including contacting air traffic services.

To highlight this issue, the ATSB has released a safety campaign ‘Don’t push it – Don’t go’.


Download Final report
[Download  PDF: 661KB]

The investigation

General details
Date: 25 February 2021   Investigation status: Completed  
Time: 16:15 ESuT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): near Warrnambool Aerodrome   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: VFR into IMC  
Release date: 16 July 2021   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  
Anticipated completion: 3rd Quarter 2021    

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-28-161  
Aircraft registration VH-FPS  
Serial number 28-16119  
Operator Aviation Management Services Pty Ltd  
Type of operation Flying Training  
Sector Piston  
Damage to aircraft Nil  
Departure point Warrnambool, Victoria  
Destination Moorabbin, Victoria  
Last update 21 July 2021