Aviation occurrence briefs

VFR into IMC and loss of control involving a Piper PA-28, 67 km west-north-west of Sydney, NSW, on 20 October 2020

Number:
AB-2020-047
Status: Completed
Investigation completed

Brief

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

What happened

On the morning of 20 October 2020, a Piper PA-28-181 departed Bankstown Airport on a private flight to Gilgandra, New South Wales, with the pilot as the sole occupant. The en-route weather forecast obtained the morning of departure indicated some cloud over the Blue Mountains to the west of Sydney, but the pilot assessed that conditions would be suitable for flight under visual flight rules (VFR).

After departure, the pilot deviated off the direct track to avoid active restricted airspace before manoeuvring to resume the flight-planned track. The pilot reported that there were scattered clouds in the area at the time. While making the track adjustment, the pilot diverted their attention to the flight log and maps. When the pilot looked up, the aircraft had entered an area of low thick clouds and the pilot initiated a turn to vacate the area.

During the turn, the pilot became disoriented in cloud and the aircraft entered a spiral dive. The pilot recovered control of the aircraft clear of cloud, but the aircraft had descended over 2,000 ft and was surrounded by mountainous terrain. With low cloud over the mountains, visual meteorological conditions[1] did not exist. To maintain terrain clearance, the pilot initiated a climbing turn, which subsequently took the aircraft back into cloud.

Once at a safe altitude, the pilot attempted to contact air traffic control (ATC) with a request but was twice asked to ‘stand by’. Approximately 2 minutes after the first radio call, the pilot made a PAN PAN[2] call reporting that the aircraft was ‘VFR in cloud’. The controller immediately responded and provided assistance for the next 16 minutes, guiding the pilot away from high terrain and to an area of clear of cloud. Once below cloud, the pilot resumed visual navigation back to Bankstown.

Safety message

SafetyWatch

The ATSB 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 is inflight decision-making.

The decision to proceed is the first decision the VFR pilot faces when confronted with less than visual meteorological conditions. Flight Safety Australia article ‘178 seconds to live’, illustrates the stark reality of attempting to fly in IMC conditions without adequate training.

The ATSB strongly urges pilots to seek assistance from ATC as soon as conditions deteriorate. Controllers are trained to handle such an occurrence and providing them with accurate information on your situational awareness and in-flight conditions will allow them to provide the best possible assistance.

The ATSB continues to investigate weather-related general aviation accidents. VFR into IMC remains one of the most significant causes for concern in aviation safety; the often-fatal outcomes of these accidents are usually avoidable. In the 5 years prior to the occurrence, there were 56 reported VFR into IMC occurrences, 7 of which resulted in accidents, with 10 fatalities.

The ATSB publication Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions provides investigation findings, case studies and further reading on managing the risks of flying in reduced visibility.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.

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  1. Visual Meteorological Conditions (VMC): an aviation flight category in which visual flight rules (VFR) flight is permitted – that is, conditions in which pilots have sufficient visibility to fly the aircraft while maintaining visual separation from terrain and other aircraft.
  2. PAN PAN: an internationally recognised radio call announcing an urgency condition which concerns the safety of an aircraft or its occupants but where the flight crew does not require immediate assistance.
General details
Date: 20 October 2020   Investigation status: Completed  
Time: 0840 EDT    
Location   (show map): 67 km west-north-west of Sydney    
State: New South Wales    
Release Date: 10 December 2020   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-28  
Type of operation Private  
Sector Piston  
Damage to aircraft Nil  
Departure point Bankstown, New South Wales  
Destination Gilgandra, New South Wales  
Last update 10 December 2020