Van Hattem, Martinus and Applebee, Trista-Lea

Contributing factors

• Low-level aerobatic manoeuvres performed below 3000 feet, contrary to endorsement restrictions
• Deficient flight activity endorsement training (approximately 2 hours versus required 8-10 hours minimum)
• Lack of experience flying YAK 52 aircraft (39.4 hours total)
• Flight instructor (Doug Field) lacking recent experience and appropriate qualifications in YAK 52 aerobatics
• Potential interference with flight controls from loose articles (mobile phone, tools) during aerobatic manoeuvres
• Inadequate passenger safety briefing (did not comply with regulatory requirements)
• Use of Mueller-Beggs spin recovery method of questionable suitability for YAK 52
• Pilot non-compliance with air regulations and history of unauthorised low-level aerobatics
• Inadequate regulatory oversight of flight instructor competence and training standards
• Incomplete incorporation of UK Mandatory Permit Directives into AWAL maintenance schedules
• Gaps in airframe life limit assessment for YAK 52 aircraft
• Insufficient Permit Index assessment procedures

Coroner's recommendations

1. CASA should review the extent to which its surveillance of flight instructors who conduct flight training for a flight activity endorsement of a pilot of a Warbird aircraft is sufficient and effective to ensure that those flight instructors are appropriately managing their safety risks, are complying with all relevant regulations and understand the requirements of applicable flight instructor standards of performance when conducting such endorsement training.
2. CASA should consider whether all flight instructors accredited to provide training and instruction for flight activity endorsements should be required to provide a minimum period or duration of training and instruction with relevant aerobatic manoeuvres and tasks demonstrated and performed in an appropriate sequence under an approved syllabus of flight activity endorsement training.
3. CASA is urged to include within the foreshadowed investigation a consideration of whether the Mueller/Beggs method of spin recovery should continue to be included as a component of the syllabus of flight activity endorsement training conducted by a flight instructor in a YAK 52 aircraft.
4. CASA should review the English version of the Aircraft Flight Manual or Pilot Operating Handbook for YAK 52 aircraft to ensure that it provides sufficient information for pilots relating to aerobatic manoeuvres and spin recovery techniques that enable the pilot in command to comply safely with the requirements, instructions, procedures or limitations concerning the operation of the aircraft that are set out in the AFM or POH.
5. CASA and AWAL should take appropriate steps to: ensure that a risk-based assessment of the available evidence concerning incidents in which objects or loose articles have moved to the rear of YAK 52 aircraft in the course of aerobatic manoeuvres, adversely affecting elevator control of the aircraft, is undertaken; and determine whether mandating the installation of foreign object damage barriers in the rear fuselage of YAK 52 is a necessary or desirable safety measure to be taken in an appropriate manner.
6. CASA should undertake and complete a comprehensive review and assessment of the need to establish an approved airframe life limit for YAK 52 type aircraft in Australia having regard to: the ATSB report of its investigation into the air accident involving VH-PAE; relevant United Kingdom Mandatory Permit Directives; airworthiness information obtained from the designer of the aircraft (A.S. Yakovlev); airworthiness information obtained from the manufacturer of the aircraft (Aerospace SA); and any other relevant airworthiness information and foreign state or foreign authority material that may be obtainable by CASA dealing with the issue of an appropriate airframe life for the YAK 52 aircraft type.
7. CASA and AWAL should review the way in which the existing Permit Index Assessment system for limited category aircraft is used, interpreted and applied by AWAL, in relation to YAK 52 aircraft, to ensure that any risks to public safety posed by such aircraft, especially if flown over populous areas in the course of aerobatic flights, are fully, adequately and consistently assessed in accordance with the stated objectives of the Permit Index Assessment System.