Inquest into the death of Andrew Alan Thomas WILSON
Deceased
Andrew Alan Thomas Wilson
Demographics
27y, male
Date of death
2010-06-15
Finding date
2015-08-14
Cause of death
Effects of fire and inhalation of products of combustion sustained when the aircraft he was piloting suffered engine failure and impacted with the ground and became engulfed in flames
AI-generated summary
A 27-year-old pilot died when the aircraft he was piloting experienced engine failure during cruise, resulting in impact with the ground and fire. The death was caused by effects of fire and inhalation of combustion products. The coroner identified that guidance material for multi-engine aeroplane operations and engine failure procedures (CAAP 5.23) was incomplete at the time. Key clinical lesson: although this is an aviation case rather than a healthcare matter, the underlying principle mirrors clinical practice—clear, finalised guidance protocols for managing critical emergencies (engine failure equivalent to clinical decompensation) must be completed, accessible, and universally applied. System-level failures in regulatory guidance and inability to compel witness testimony hampered investigation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Engine failure during cruise
- Incomplete guidance material for multi-engine aeroplane operations and engine failure procedures (CAAP 5.23)
- Regulatory framework lacking power to compel sworn interviews regarding aviation safety risks
Coroner's recommendations
- CASA finalise the guidance material for CAAP 5.23 for multi-engine aeroplane operations and training to support flight standard in Appendix A of s.1.2 relating to engine failure in the cruise, to be completed and released as soon as possible
- CASA undertake public consultations to develop a legislative proposal enabling CASA to compel attendance of persons at compulsory sworn interviews to answer questions concerning specific aviation and safety measures where reasonable suspicion exists that a significant safety risk exists or existed in an aviation operation and evidence of witnesses cannot be obtained in any other way
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