An ATSB investigation has found irregular flight school practices likely contributed to a pilot's inadequate understanding of stall conditions prior to a fatal light aircraft accident north of Sale, in Victoria's east.
On 16 November 2024, an amateur-built experimental certificate Morgan Cougar Mk 1 light aircraft took off from West Sale Airport, in Victoria's Gippsland region, for a local area flight, with a pilot and two passengers on board.
All three occupants were fatally injured when the aircraft collided with terrain in a paddock, 17 minutes later.
Witness statements, CCTV, flight data and site and wreckage examination led the ATSB to conclude the aircraft had entered an accelerated stall while in a steep turn.
"The stall occurred during the third orbit over the area, the lowest and slowest of the three," Chief Commissioner Angus Mitchell explained.
"As the aircraft turned steeply to the left it entered a stall, at a height too low to recover."
The ATSB's final report notes the pilot held a valid pilot licence, granted by the Civil Aviation Safety Authority (CASA) three months before the accident, in recognition of the pilot already holding a recreational pilot certificate issued earlier by Recreational Aviation Australia (RAAus).
"During this investigation the ATSB interviewed several parties involved with the Adventure Flight Training school, where the pilot acquired their RAAus certificate," Mr Mitchell said.
"These accounts, as well as an examination of available records, identified a series of irregularities with the way the school trained and examined its pilots for certification."
A specific review of the pilot's exam history revealed several errors about aerodynamic stalling in exams conducted during 2024, and it was concluded the pilot likely had inadequate knowledge of the relationship between angle of bank, load factor and stall speed.
"The pilot had a reported history of conducting low flying and slow steep turns," Mr Mitchell said.
"In addition, the aircraft was newly acquired by the pilot, and they had not received transition training, so were likely unaware that, while the accelerated stall characteristics of the accident aircraft were unknown, there were indications that it would be abrupt."
It was also found that the pilot had been counselled on several occasions about unsafe flying practices, but nothing was reported to any authorities, and therefore no official follow-up action was ever initiated.
"The investigation revealed a trend of risky flying behaviour by the accident pilot, which was likely compounded by inadequate knowledge from a flight training school that had developed irregular practices in the delivery of training and had inadequate supervision," Mr Mitchell summarised.
"While many people knew of the pilot's risky flying behaviour and had attempted to counsel them, there was no evidence that any of the incidents were reported to authorities, and the counselling efforts were ultimately unsuccessful."
The ATSB has previously advocated for witnesses, particularly those within the aviation industry, to report any concerns regarding unsafe behaviours through mechanisms such as confidential reporting systems, and Mr Mitchell reiterated this message.
The ATSB's investigation also noted that, as the approved self-administering organisation for recreational aviation, RAAus administered the examination system.
"The ATSB found RAAus had inadequate controls to mitigate the irregular examination practices identified at the flying training school," Mr Mitchell said.
Prior to the accident in 2024, RAAus identified problems at Adventure Flight Training and issued a safety related suspension notice against its chief flying instructor, which resulted in cessation of flight school operations in August 2024, three months before the accident.
After the accident, RAAus issued another safety related suspension, this time against all Adventure Flight Training school graduates, for potential knowledge deficiencies.
However, when CASA was advised of this action, it did not follow up to verify if any of those graduates had, like the accident pilot, used their RAAus certificates to acquire a CASA licence.
"It was subsequently found that two more pilots held a CASA-issued licence, granted based on the RAAus certificates they had earned at the Adventure Flight Training school," Mr Mitchell said.
RAAus has commenced a digital systems redevelopment project, which includes its learning management system, and incorporates the implementation of an online exam system.
CASA has implemented a more robust process to ensure that all reports received relating to suspensions, variations or cancellations of authorisations issued by an approved self‑administering organisation, such as RAAus, will trigger a review of CASA records.
Aircraft design deficiencies also identified
The ATSB investigation also identified the accident aircraft had design deficiencies, which contributed to the severity of the occupants' injuries.
"These issues included a lack of energy attenuation in the landing gear and seating, and the installation of a fuel tank between the engine and instrument panel that ruptured and caused the post-crash fire," Mr Mitchell said.
Mr Mitchell pointed to the ATSB's ongoing SafetyWatch priority of reducing the severity of injuries in accidents involving small aircraft.
"Given the importance of energy attenuation for crashworthiness, and the susceptibility of aircraft fuel tanks to rupturing, the ATSB concluded that the amateur-built industry could benefit from additional guidance in these areas," Mr Mitchell said.
However, the final report notes, CASA's guidance material for amateur-built experimental aircraft does not recommend consideration of the crashworthiness of seating and fuel tank installation.
"These characteristics within the design of the aircraft, in this case, increased the risk of occupant injuries, and I would urge amateur builders and designers to consider these factors for their own aircraft," Mr Mitchell concluded.
You can find here the final report: Loss of control and collision with terrain involving a Morgan Cougar Mk1 aircraft, VH-LDV, 19 km north-north-west of West Sale Airport, Victoria, on 16 November 2024
