The ATSB's investigation of an accident involving a Cessna 206 survey aircraft in south‑east WA highlights to air work operators the importance of ensuring risks inherent to their operations are effectively managed.
The single piston-engined Cessna U206G, operated by MAGSPEC Aviation, collided with terrain during a geophysical survey flight 124 km west of Norseman on 3 March 2022, the investigation report details. Recorded data showed the flight's first survey line commenced at 1252 local time, and the aircraft's last recorded position occurred at 1343, in the survey area.
The wreckage and the fatally injured pilot were found five hours later, although an earlier emergency response was unlikely to have altered the outcome due to the extent of the pilot's injuries.
"The emergency response was not initiated until 30 minutes after the aircraft's estimated time of arrival, which was 3 hours after satellite tracking had stopped and attempts to contact the pilot had been unsuccessful," ATSB Chief Commissioner Angus Mitchell said.
"Although an earlier response was very unlikely to have altered the outcome in this tragic case, minimising the time for search and rescue and enabling emergency services to respond as quickly as possible is essential."
Mr Mitchell said the ATSB investigation concluded control of the aircraft was likely lost at a height from which recovery was not possible during a manoeuvre to intercept the next survey line.
"While an aerodynamic stall situation is a plausible explanation for the loss of control, this could not be conclusively established due to a lack of available evidence, including no recorded data beyond the last known position of the aircraft, and no witness observations," ATSB Chief Commissioner Angus Mitchell said.
However, Mr Mitchell said the investigation made several findings regarding risks to aviation safety that are pertinent to air work operators.
"Air work such as mustering, spraying and geophysical survey are conducted at low levels out of operational necessity, which creates an inherently high‑risk operating environment," he said.
"Operators are responsible for effectively managing this heightened risk with adequate and effective processes and controls."
The investigation found MAGSPEC Aviation's risk management processes did not include a pre-operational risk assessment to consider the generic risks and hazards common across low‑level survey operations.
"Further, a risk register was not maintained, limiting the operator's ability to track, monitor, and mitigate all known hazards, and assess the effectiveness of the existing risk controls."
Pilots routinely flew survey patterns using steep turns at low level, in accordance with their operator-provided training.
"Procedures or limitations specific to these manoeuvres were not included in the operations manual, increasing the risk of inconsistencies in the application of those manoeuvres and reducing the safety margins available," Mr Mitchell observed.
Since the accident, MAGSPEC Aviation has updated its manuals and procedures, and implemented a range of other measures targeted at improving safety in its low‑level survey operations.
The investigation also identified that, while not established as contributory to the accident, the Civil Aviation Safety Authority's regulatory oversight of the operator had not considered the operator's primary activity of low‑level survey flights, or the processes and procedures designed to reduce the risks associated with that activity.
You can find here the final report: Collision with terrain involving a Cessna U206G, VH-JVR, 124 km west of Norseman, Western Australia, on 3 March 2022
