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Final report of VH-PXD fatal accident released.

Via the ATSB: https://www.atsb.gov.au/publications/inv...-2016-006/

What happened

On the morning of 29 January 2016, a Piper Aircraft Corp PA-28 aircraft, registered VH-PXD, was on a private flight from Moorabbin Airport, Victoria to King Island, Tasmania. After passing over Point Lonsdale, the aircraft entered an area of low visibility. The pilot conducted a 180° turn and initially tracked back towards Point Lonsdale, before heading south over the ocean. After about 2 minutes, the aircraft was again turned right before entering a rapid descent. The aircraft impacted the water at 1227 Eastern Daylight-saving time, 6.6 km south-west of Point Lonsdale. All four occupants of the aircraft were fatally injured.

What the ATSB found

The ATSB found that continuation of the flight beyond Point Lonsdale, and towards an area of low visibility conditions, was likely influenced by the inherent challenges of assessing those conditions.

The ATSB also found that due to the presence of low cloud and rain, the pilot probably experienced a loss of visual cues and became spatially disorientated, leading to a loss of control and impact with the water. The risk of a loss of control in the conditions was increased by the pilot’s lack of instrument flying proficiency.

Safety message

Pre-flight planning needs to include consideration of not only the conditions on departure, but at all stages of the flight. This informs the decision of whether to depart and allows for prior consideration of alternative actions in the case of deteriorating weather, such as returning or diverting.

It is always possible that the actual weather conditions will be different to those forecast. Pilots conducting a flight under the visual flight rules make every effort to avoid areas of low visibility and plan for unforeseen eventualities. However, this is dependent on the pilot perceiving the risks of the situation, which is not inherently easy. Education and training in the practical application of meteorological principles has been shown to enhance pilots’ ability to recognise and respond to deteriorating weather conditions.

The ATSB cautions that, on entering an area of reduced visual cues, the risk of experiencing spatial disorientation and a loss of control is high, measuring from between 60 to 178 seconds from the time of entering the area of low visibility. This risk is highest for those without proficiency or recent experience in instrument flying. Requesting assistance from air traffic control can increase the chances of re-establishing visual cues.

Via the Age:

June 29 2017 - 6:53PM
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[url=http://www.theage.com.au/victoria/180-seconds-to-tragedy-fatal-point-lonsdale-crash-blamed-on-poor-visibility-20170628-gx0v4b.html]180 seconds to tragedy: Fatal Point Lonsdale crash blamed on poor visibility

• Tom Cowie
  

All up it took just three minutes.

That's how much time elapsed between a light plane entering an area of low cloud over Point Lonsdale and finally plunging into the water, killing all four people on board. 

The wreckage of the plane that crashed near Point Lonsdale. Photo: Paul Jeffers  

Experienced aviators Daniel Flinn, Donald Hateley, Ian Chamberlain and Dianne Bradley were killed on January 29 last year when a 1967 Piper PA-28 Cherokee plummeted into the ocean without making a distress call.

Nearly 18 months after the crash, the Australian Transport Safety Bureau has released its report into what happened during the tragic flight.

A photo of the plane taken many years before the crash.  Photo: ATSB  

But after all that time one key fact still eludes investigators: the identity of the pilot. 

While three of the people on board the plane held pilot licences, the bureau said it failed to uncover any definitive evidence as to which one was in command when it went down. 

The final flight of the plane registered VH-PXD began at 12.03pm, when it left Moorabbin Airport for King Island. The pilot made a radio transmission about 12.09pm reporting on cloud conditions over the suburb of Carrum.

Eighteen minutes later the plane had crashed into water, 6.6 kilometres south-west of Point Lonsdale.

A CCTV image from Port of Melbourne cameras facing east across the water from Point Lonsdale show the weather conditions.  Photo: ATSB  

Reduced visibility due to low cloud and rain was the likely cause of the crash, the bureau found.

This led to the pilot experiencing "spatial disorientation", a perilous and often fatal condition that results in loss of perspective from the horizon.

Donald Hateley, who died in the plane crash. Photo: supplied  

According to the Civil Aviation Safety Authority, spatial disorientation occurs when "your senses are telling you something that isn't true – typically that you are flying straight and level when in fact you are in a spiral dive". 

Analysis of the plane's final flight path shows it made several sweeping turns
after passing over Point Lonsdale before a final steepening and rapidly descending turn as the plane hit trouble. 

A memorial image at Point Lonsdale Lighthouse for Ian Chamberlain and Dianne Bradley. Photo: Justin McManus  

The series of left and right turns may have been an effort by the pilot to avoid cloud and improve visibility, the safety bureau said. However, the turns could also have contributed to the effects of spatial disorientation.

"The time from PXD entering the area of low visibility to impacting the water was about 180 seconds," the report said. 

Witnesses fishing in the vicinity of Point Lonsdale at the time told the bureau they heard an aircraft pass nearby at what they interpreted to be a "very low altitude".

"Due to the low cloud and visibility in the area they could not initially see the aircraft. The witnesses recalled that, a few minutes later, they saw the aircraft just before it impacted the water," the report said.

"It appeared to be in a nose-down, right wing-low attitude and the engine sounded as though it was producing power."

No one on board the plane was qualified to fly using instruments like GPS and the flight was being conducted according to visual cues.

The group was flying as part of a loosely organised group of Royal Victorian Aero Club members attending the Festival of King Island and the final day of horse racing for the summer.

Another pilot who left for King Island before VH-PXD returned because of reduced visibility near Point Lonsdale, believing it was caused by nearby storms. Two pilots who left after the doomed plane continued to King Island, although they also reported reduced visibility.

The bureau said it was unable to establish whether the people on board the crash plane were fully aware of the deteriorating weather they were flying into. 

MTF...P2