Finding into death of Andrew Phillip Mull
Deceased
Andrew Phillip Mull
Demographics
34y, male
Date of death
2006-03-29
Finding date
2009-12-22
Cause of death
Multiple injuries sustained in helicopter crash caused by tail rotor failure
AI-generated summary
Andrew Mull, a 34-year-old builder and pilot, died when his homebuilt Rotorway Exec 162 helicopter crashed on 29 March 2006 near Mount Beauty, Victoria. The coroner found tail rotor failure was the likely cause of the crash. Critical systemic failures included: inadequate oversight of kit helicopter construction by CASA, Andrew's minimal involvement in his helicopter's build despite claiming major participation, lack of independent airworthiness verification, absence of endorsement training on the Rotorway despite training on a different aircraft type (Robinson 22), and Andrew's limited maintenance knowledge. The coroner noted Andrew continuously experienced vibration issues post-licensing but lacked the training to diagnose or rectify problems. His reliance on the helicopter's distributor Kevin Lunn for advice proved insufficient when critical failures emerged. The coroner criticised the regulatory framework treating kit helicopters as 'experimental aircraft' without adequate safety oversight, design standards, or independent testing requirements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Tail rotor belt-pulley drive system failure
- Inadequate CASA oversight of kit helicopter construction and licensing
- Insufficient verification of homebuilder's participation in aircraft construction
- Lack of independent airworthiness assessment
- Absence of endorsement training on Rotorway aircraft type
- Builder's minimal maintenance knowledge and training
- Reliance on distributor for technical guidance without independent qualified support
- Ongoing unresolved vibration issues not grounded for investigation
- No requirement for qualified maintenance personnel
- Design deficiency in belt-driven tail rotor system compared to shaft-driven alternatives
Coroner's recommendations
- Distinguish kit build helicopters from other 'experimental aircraft' and develop a separate, distinct legal framework
- Issue an Airworthiness Directive prohibiting flying of all Rotorway Exec 162 aircraft immediately until manufacturer satisfies design and build standards established by CASA in consultation with the manufacturer, and until each owner demonstrates compliance through flight testing
- Prohibit future building and maintenance of Rotorway Exec 162 aircraft by non-LAME qualified persons or non-CASA approved qualified persons
- Require appropriate endorsement level training in Rotorway Exec 162 aircraft (or similar aircraft approved by CASA) before issuing pilot licences, upgrades, or renewals
- Place additional limitations on future licensing arrangements for Rotorway Exec 162 to provide reasonable safety levels for pilots, passengers, and community members
- Deputy Premier and Attorney General to provide findings to Federal Minister for Transport and liaise regarding regulatory changes needed
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