Ganter, Wayne Joseph; Rawlings, Mark Robert; Roebig, Henry Phillip; Brischke, Wayne Anthony; and Weavell, Stuart Henry Russell…
Deceased
Wayne Joseph Ganter, Mark Robert Rawlings, Henry Phillip Roebig, Wayne Anthony Brischke, Stuart Henry Russell Weavell
Demographics
male
Date of death
2020-03-11
Finding date
2023-08-30
Cause of death
Multiple injuries due to or as a consequence of an aircraft accident (controlled flight into terrain)
AI-generated summary
On 11 March 2020, a Cessna 404 aircraft carrying five people crashed near Lockhart River, Queensland, killing all occupants. The pilot attempted two RNAV GNSS instrument approaches in poor weather with heavy rain and low visibility. During the second approach, the pilot was flying approximately 1,000 feet below the recommended descent profile. Analysis indicates the pilot likely misread his analogue altimeter due to very high workload from single-pilot operations in instrument meteorological conditions, lateral navigation corrections, excessive airspeed, and rain. The pilot descended below minimum descent altitude and impacted sand dunes 6.4 km short of the runway. A terrain avoidance warning system (TAWS) was not installed, though fitting one would likely have prevented the accident. Key lessons include the critical importance of mandating TAWS installation for commercial charter operations, upgrading to modern avionics providing vertical guidance, improving stabilised approach criteria aligned with international best practice (1000 ft applicable height in IMC), and enhancing pilot proficiency monitoring in instrument approaches.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- pilot misread analogue altimeter by approximately 1,000 feet
- very high workload due to single-pilot hand flying in instrument meteorological conditions
- immediate entry into second approach without adequate rest or holding pattern
- conducting approach in different manner to normal method
- need to correct lateral tracking deviations throughout approach
- excessive aircraft speed (140-150 knots versus recommended 110 knots)
- pilot did not effectively monitor altitude and descent rate for extended period
- heavy rain and significantly reduced visibility
- aircraft descended below minimum descent altitude before missed approach point
- lateral position exceeded full-scale deflection on course deviation indicator for extended period without conducting missed approach
- aircraft not fitted with terrain avoidance warning system (TAWS)
- aircraft not fitted with system providing vertical guidance on non-precision approaches
- limitations in operator's stabilised approach criteria design
- lack of procedures or guidance for terrain awareness function on GNS 430W units
- limited monitoring of line operations by operator
- inadequate regulatory guidance on stabilised approach criteria in Australia
Coroner's recommendations
- CASA to implement regulation mandating fitment of TAWS for all small aeroplanes conducting air transport operations under IFR (and night VFR) where the aeroplane has a passenger carrying capacity of 6 or more, regardless of whether turbine or piston powered
- CASA in consultation with Airservices Australia and aerodrome operators to consider best way to monitor use of Baro-VNAV procedure at sample or selected aerodromes including Lockhart River, with view to assessing effectiveness and whether steps needed to encourage operators to use such procedures
- CASA provide further information and aviation safety advice and education to relevant industry sectors about hazards of conducting instrument approaches (including RNAV GNSS) in IMC and importance of maintaining comprehensive and competent systematic scan technique in hazardous weather conditions including turbulence
- CASA provide further information and aviation safety advice and education to flight examiners conducting Instrument Proficiency Checks regarding need to fully assess and check competence of pilots conducting RNAV GNSS approaches in maintaining comprehensive and competent systematic scan technique in hazardous weather conditions
- CASA review and amend existing general guidance material (Advisory Circular AC 1-02) to include appropriate recommendations and guidance on exposition content addressing requirements of pilot conducting instrument approach procedure, and consider how to conduct surveillance of exposition content of existing Australian air transport operators regarding stabilised approach procedures
- Federal Minister for Infrastructure, Transport, Regional Development and Local Government in consultation with Lockhart River Aerodrome Company Pty Ltd to review adequacy of lighting facilities at LHR aerodrome with view to providing grants or funding for installation of upgraded lighting such as Precision Approach Path Indicator (PAPI) lighting to provide visual approach slope information
Full text
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