Collision with Terrain Mount Hotham, Victoria 8 July 2005 Piper Aircraft
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ATSB TRANSPORT SAFETY INVESTIGATION REPORT Aviation Occurrence Report – 200503265 Final Collision with Terrain Mount Hotham, Victoria 8 July 2005 VH-OAO Piper Aircraft Corporation PA31-350 Navajo Chieftain ATSB TRANSPORT SAFETY INVESTIGATION REPORT Aviation Occurrence Report 200503265 Final Collision with Terrain Mount Hotham, Victoria 8 July 2005 VH-OAO Piper Aircraft Corporation PA31-350 Navajo Chieftain Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office location: 15 Mort Street, Canberra City, Australian Capital Territory Telephone: 1800 621 372; from overseas + 61 2 6274 6590 Accident and serious incident notification: 1800 011 034 (24 hours) Facsimile: 02 6274 6474; from overseas + 61 2 6274 6474 E-mail: [email protected] Internet: www.atsb.gov.au © Commonwealth of Australia 2006. This work is copyright. In the interests of enhancing the value of the information contained in this publication you may copy, download, display, print, reproduce and distribute this material in unaltered form (retaining this notice). However, copyright in the material obtained from non- Commonwealth agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. Subject to the provisions of the Copyright Act 1968, you must not make any other use of the material in this publication unless you have the permission of the Australian Transport Safety Bureau. Please direct requests for further information or authorisation to: Commonwealth Copyright Administration, Copyright Law Branch Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 www.ag.gov.au/cca ISBN and formal report title: see ‘Document retrieval information’ on page v. – ii – CONTENTS THE AUSTRALIAN TRANSPORT SAFETY BUREAU ..................................vii EXECUTIVE SUMMARY........................................................................................ix 1 FACTUAL INFORMATION ............................................................................1 1.1 History of the Flight..................................................................................1 1.2 Injuries to persons .....................................................................................6 1.3 Damage to aircraft.....................................................................................6 1.4 Other damage ............................................................................................6 1.5 The Pilot.....................................................................................................6 1.6 Aircraft information..................................................................................8 1.6.1 Aircraft data ............................................................................8 1.6.2 Aircraft maintenance, serviceability and equipment............8 1.7 Meteorological information......................................................................8 1.7.1 Weather forecasts ...................................................................8 1.7.2 Observed weather conditions.................................................9 1.8 Aids to navigation .....................................................................................9 1.9 Communications .......................................................................................9 1.10 Aerodrome information ..........................................................................10 1.11 Flight recorders .......................................................................................10 1.12 Impact and wreckage information..........................................................10 1.13 Medical information................................................................................10 1.14 Fire ...........................................................................................................10 1.15 Survival aspects.......................................................................................10 1.16 Tests and research ...................................................................................11 1.16.1 Controlled flight into terrain and approach and landing accidents................................................................................11 1.16.2 Flying in flat light conditions ..............................................11 1.17 Organisational information.....................................................................11 1.18 Additional information ...........................................................................12 1.18.1 CASA surveillance of the operator .....................................12 2 ANALYSIS..........................................................................................................15 2.1 Introduction .............................................................................................15 2.2 Weather conditions .................................................................................15 2.2.1 Flat light phenomena and the approach path ......................15 – iii – 2.2.2 Airframe icing.......................................................................15 2.3 Operational decision making processes.................................................16 2.4 Provision of air traffic services ..............................................................17 2.5 Aviation safety regulation ......................................................................17 3 CONCLUSIONS ................................................................................................19 3.1 Findings ...................................................................................................19 3.2 Significant factors ...................................................................................19 4 SAFETY ACTION ............................................................................................21 4.1 Recommendations...................................................................................21 4.2 Civil Aviation Safety Authority.............................................................21 4.3 Australian Transport Safety Bureau.......................................................22 4.4 Flight Safety Foundation ........................................................................22 5 APPENDIXES ....................................................................................................25 5.1 APPENDIX A Mount Hotham automatic weather station data...........25 5.2 APPENDIX B The Dash 8, Cessna Citation and Chieftain flight tracks at Mount Hotham .........................................................................27 5.3 APPENDIX C Air traffic control sector areas ......................................28 5.4 APPENDIX D Mount Hotham weather forecasts.................................29 MEDIA RELEASE....................................................................................................33 – iv – DOCUMENT RETRIEVAL INFORMATION Report No. Publication date No. of pages ISBN ISSN 200503265 May 2006 45 1 921092 52 1 Publication title Collision with Terrain - Mount Hotham, Victoria - 8 July 2005 VH-OAO - Piper Aircraft Corporation PA31-350 Navajo Chieftain Prepared by Australian Transport Safety Bureau PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au Acknowledgements Background maps for Figure 1 and Figure 4 provided by Google Earth. Abstract On 8 July 2005, the pilot was conducting a charter flight, with two passengers on board, in a Piper PA31-350 Navajo Chieftain. The flight was initially planned to proceed from Essendon Airport to Mount Hotham, Victoria. However, because of adverse weather, the pilot revised his destination to Wangaratta. While en route, he diverted the aircraft to his originally intended destination, Mount Hotham. The pilot subsequently reported to air traffic control that he was overhead Mount Hotham. He changed the flight category from visual flight rules to instrument flight rules and advised his intention to conduct an instrument approach to runway 29. At about 1725, the pilot told the Mount Hotham Airport Manager by radio that he was on final approach for runway 29 and asked him to switch on the runway lights. After doing so, the manager attempted to tell the pilot that the lights had been switched on, but received no response. Subsequent attempts by air traffic control and the crews of other aircraft to contact the pilot were also unsuccessful. Because of hazardous weather conditions over the following two days, the search for the aircraft was primarily conducted on foot and horseback. The aircraft was located on a tree covered ridge, partially covered by snow. It had flown into trees in a level attitude, slightly banked to the right. Initial impact with the ridge was at about 200 ft below the elevation of the Mount Hotham aerodrome. The Chieftain had broken into several large sections and an intense fire had consumed most of the cabin. The occupants were fatally injured. The investigation determined that the aircraft systems had been operating normally. The weather conditions were ideal for a ‘flat light’ phenomenon that was likely to have denied the pilot adequate visual reference. The pilot may have experienced disorientation and loss of situational awareness. The aircraft was not equipped for flight in icing conditions, nor had the pilot complied