Coroner's Finding: IRVINE Samantha and SAKAMOTO Goro

Contributing factors

• Inadequate lookout by glider pilot despite prior training emphasis
• Language barrier affecting radio communication and comprehension
• Lack of proper documentation of pilot training competencies
• Inadequate use of CTAF (Common Traffic Advisory Frequency) for traffic alerting
• Shared airspace between aero-towing aircraft and gliders without adequate separation procedures
• Lack of radio call from glider pilot upon entering circuit area
• Ineffective traffic warning broadcast
• Insufficient training and oversight of foreign pilot in Australian aviation environment

Coroner's recommendations

1. The Gliding Federation of Australia in conjunction with its member clubs should incorporate the use of radio for effective traffic alerting into standard operating practices as a matter of priority.
2. The Civil Aviation Safety Authority should review the assessment process for the issue of a radiotelephone operator certificate of proficiency or equivalent, as specified by Civil Aviation Regulations subregulation 83A(2) and subregulation 83E(1)(a) and establish competency standards for those applicants for whom English is a second language, especially in respect of a candidate's ability to effectively communicate and comprehend traffic information.
3. The Gliding Federation of Australia should adopt measures to make all aircraft engaged in gliding activities more conspicuous.
4. The Gliding Federation of Australia should consider developing procedures that permit segregation of aero-towing and gliding activity.
5. The Gliding Federation of Australia should develop a checklist of core competencies for use in training glider pilots which should be acknowledged in writing, in English, as a permanent record that a particular pilot achieved a particular standard on a particular day, to the satisfaction of a particular instructor.