This VFR-into-IMC accident, like many others, was the Swiss cheese variety, with multiple factors lining up to produce a familiar result

Ten years ago, I spent a winter building my CPL hours by sharing flights with a gentleman who was pushing 80 years. Together we would hire a Piper Warrior from Camden and each fly a leg to a regional NSW town and back.

Having achieved his licence at the age of 68, Bob knew his limitations and never flew solo, even though he was fully licenced to. I also knew the limitations of my licence and appreciated the opportunity to share the cost of a flight, but also thoroughly enjoyed the company of a pilot who was thoughtful, considered and self-aware.

What struck me most about my time flying with Bob was his utter lack of ego – he was aware his age slowed him down and had systems in place to double and triple check his memory. He never rushed; he gave himself the whole day for an afternoon’s flight and, if interrupted in any stage of a flight check, would start again at the beginning.

Another point Bob would always make is that flying with another pilot – and he loved that we were from different generations – kept him up-to-date. ‘It’s very easy for old pilots like me to slip through the net,’ he said.

We’d chat about his rural friends who owned their own 182s and Jabirus, lived on farms, never flew into controlled airspace and conducted the same flights over and over again. Bob worried they were rusty.

I haven’t seen Bob since 2011, but whenever I come across an ATSB report where there are certain causes to an accident, I think of his ‘slipping though the net’ comment.

We can learn a lot by examining how a series of small oversights can add up to one very large one, as demonstrated in the following report.

Controlled flight into terrain involving Mooney M20J, VH-DJU
West of Coffs Harbour Airport, NSW, 20 September 2019.

What happened

About 0640 Eastern Standard Time on 20 September 2019, a Mooney M20J departed Murwillumbah, NSW for a private VFR flight to Taree, NSW. On board were the pilot and one passenger.

At 0717, about 45 nm north of Coffs Harbour, the pilot contacted ATC and requested a clearance to transit the Class C controlled airspace at 6500 feet. ATC advised a clearance was not available at that altitude and that, due to cloud conditions, a visual transit of the airspace would only be possible at an altitude not above 1000 feet. The pilot then advised the flight would descend to ‘not above 1000 feet’.

The aircraft continued on a direct track to Taree and at 0724, the pilot reported the aircraft was operating outside controlled airspace in clear conditions at 4100 feet and would remain on that track. The aircraft was then climbed to 4500 feet and, at 0732, commenced a descent in the vicinity of high terrain.

When the aircraft did not arrive at Taree as expected, a search was initiated. The aircraft wreckage was found about 26 km west of Coffs Harbour Airport. The 2 people onboard were dead and the aircraft was destroyed.

As with many general aviation accidents, this was the result of multiple factors. I have identified 8 factors – or holes in the net – that together resulted in this fatality.

Pilot’s recency

Licenced in 1982, the pilot was the holder of a CAR 5 licence, the validity for which expired in September 2018, the final cut-off date for the transition to the Part 61 licence.

The pilot’s last flight review appears to have been in 2010. As the pilot’s current logbook was not recovered during the investigation, the date of any flight review after January 2010 and before September 2014 could not be determined. However, CASA did not hold any record of an application for a flight review or equivalent proficiency check after September 2014.

The ATSB contacted flying training organisations where the pilot’s previous aircraft was maintained and the pilot was reported to have regularly visited. None of these organisations held training records for the pilot.

Hole one: not current. The pilot had not completed the required flight reviews or proficiency checks to maintain currency, which resulted in them not possessing the required licence to undertake the flight.

The pilot had not completed the required flight reviews or proficiency checks to maintain currency, which resulted in them not possessing the required licence to undertake the flight.

Time on type

The pilot had declared a total aeronautical experience of 1006 hours at their last medical examination in November 2017 and was endorsed for single-engine aircraft below 5700 kg maximum take-off weight, manual propeller pitch control, retractable undercarriage, tail wheel undercarriage and operation in controlled airspace. The pilot did not hold an instrument rating.

The pilot purchased the aircraft on 6 July 2019, about 3 months before the accident, and had flown about 31 hours in the aircraft.

Hole 2: low time on type. While the pilot had substantial total time, they were relatively new to the aircraft.

Equipment on board

The aircraft was equipped with an autopilot capable of maintaining a selected heading and navigation track. The autopilot did not have an altitude hold function or ability to manipulate the vertical flight profile.

Two smartphones and a tablet computer were recovered from the wreckage. Neither smartphone contained an electronic flight bag or other aviation application. The tablet computer was found packed in an overnight bag indicating it was not used during the flight.

Date-expired air navigation charts for the area encompassing the flight were found stowed in a flight bag, indicating they were not being used at the time of the accident. No paper flight plan or other flight planning notes were located in the wreckage.

The Aera 500 unit carried by the pilot was not approved as a sole means of navigation. However, the unit did present useful information relating to the progress of the flight, including topographical and airspace information.

The ATSB recovered data from this unit indicating it was in use at the time of the accident. However, it could not be established which mode was selected at the time of the accident or whether the terrain function was operable and the status of any user and system inhibitions.

The GTN650 unit fitted to the aircraft operated as both a radio communications unit and an IFR approved GNSS unit. The unit could operate in different modes, which could display information relating to progress of the flight. This included the selected track, any deviation from this track, topographical and airspace information.

The ATSB was not able to recover any data from the GTN650 unit to determine if it was used during the accident flight.

Hole 3: no flight plan. It appears there was no plan for the flight, either on paper or EFB. Charts for the area were expired.

Hole 4: inadequate equipment used. The Aera 500 is not approved for sole navigational use; however, items onboard (below) were approved, or potentially could have been.

Hole 5: equipment available on board not used. According to the report, there were several pieces of equipment onboard which may have aided navigation and terrain avoidance, including two smart phones, an autopilot and a GPS with topographical information.

Meteorological conditions

Airservices Australia did not hold any National Aeronautical Information Processing System (NAIPS) login records for the pilot for that, or any past, flights. A review of the pilot’s personal electronic devices identified there were no aviation flight planning

or aviation weather applications, and no weather documentation relevant to the accident flight was found in the wreckage.

GAF

The graphical area forecast for the accident region forecast the following cloud conditions for the time of the accident (all heights AMSL):

• broken stratus 1000–2000 ft
• broken stratocumulus 2000–4000 ft
• scattered cumulus 4000–9000 ft.

Having not checked the weather, the pilot then took off in conditions that were beyond their level of experience to handle.

ATIS

At the time of the accident, the Coffs Harbour automatic terminal information service detailed the following weather information:

• wind: variable at 5 kt
• visibility: greater than 10 km
• cloud coverage: few at 1500 ft and broken at 2500 ft
• temperature: 17 degrees.

A witness located about 10 km southeast of the accident site stated that cloud was ‘down to the ground’ at the base of the mountain from 0700 until 0830 on the morning.

Hole 6: no NAIPS account. The pilot appeared not to have a NAIPS account, suggesting they were not in the habit of logging onto NAIPS for the weather.

Hole 7: weather conditions below VMC. Having not checked the weather, the pilot then took off in conditions that were beyond their level of experience to handle.

Other contributing factors

The pilot requested a clearance to proceed from a position 10 nm north of Grafton (14 nm from the airspace boundary) direct to Taree at an altitude of 6500 feet. This track passed within the Class C airspace for about 7 nm (2 minutes and 50 seconds at the aircraft’s speed).

On receiving the clearance request, the trainee air traffic controller on duty assessed that workload and priorities would not permit a clearance at the requested level, and that the transit would be better facilitated through the underlying Class D airspace. The trainee then advised the pilot accordingly, providing the option to request clearance for the Class D airspace.

After being advised that a Class C clearance was not available, the aircraft entered the Class C controlled airspace without clearance. The pilot descended the aircraft before exiting the airspace about one minute later.

Hole 8: poor clearance decision. The pilot was not provided with a clearance to transit Class C airspace, despite no limiting meteorological factors. Instead, the Class C controller provided the option to seek a clearance at a lower altitude with an increased risk of encountering poor weather.

The limited information provided by the Class D controller to enter that airspace probably led to the pilot’s decision to descend into a hazardous area instead of other available safe options.

How does a pilot slip through the net?

While it was straightforward for Airservices Australia to implement the additional safety actions required to address the air traffic control issue – by increasing training, workload management and education – reaching out to individual pilots is a more challenging task.

Pilots who own their aircraft don’t engage with schools or clubs and live rurally are those most likely to slip through the net. Publications such as this one, along with CASA’s safety material, are of course vital, but the most effective method of ensuring diligence among pilots is via a culture of safety.

If you see another pilot struggling with technology, assist and explain; if you overhear a pilot perpetuating a dangerous myth, firmly challenge it with facts; if you notice a pilot sitting alone at an airshow or event, invite them to join you.

Safety is a culture and, if Bob taught me anything, it is you’re never too old to learn.