Finding into death of Kerry David Endicott
Deceased
Kerry David Endicott
Demographics
69y, male
Date of death
2004-07-28
Finding date
2011-09-30
Cause of death
Injuries sustained as a result of aviation accident - controlled flight into terrain (CFIT) with underlying navigation failure in GPS Dead Reckoning mode
AI-generated summary
A Piper PA-31T Cheyenne aircraft carrying six occupants crashed into terrain near Benalla, Victoria on 28 July 2004 while conducting a GPS approach in instrument meteorological conditions. The pilot, Kerry Endicott, was highly experienced (>14,000 hours) and the aircraft was well-maintained. The coroner concluded the primary cause was navigation in GPS Dead Reckoning (DR) mode, combined with critical Air Traffic Control (ATC) failures. The ATC failed to communicate track deviations when two Route Adherence Monitoring (RAM) alerts were triggered, missing opportunities to alert the pilot that the aircraft was progressively deviating 7.5+ nautical miles south of the cleared track. The ATC's poor judgment in resolving these alerts without pilot contact, reliance on pilot competence rather than procedural requirements, and failure to apply proper MATS procedures directly contributed to the accident. Enhanced TAAATS displays, mandatory pilot communication protocols for RAM alerts, and Terrain Awareness and Warning Systems could have prevented this tragedy.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Trimble GPS receiver operating in Dead Reckoning mode due to loss of satellite signal reception
- Air Traffic Control failure to communicate track deviation to pilot at two critical RAM alerts (10.23am and 10.42am)
- Air Traffic Controller (Mr Carey) exercised poor judgment in resolving RAM alerts without contacting pilot
- Failure to comply with MATS 2.8.7.1 and 2.8.7.3 requirements for RAM alert resolution
- Progressive systematic track deviation (7.5+ nautical miles to the south/left) not communicated to pilot
- Pilot reliance on GPS information while flying in IMC with no alternative visual references
- Absence of land-based navigation aids at destination airport
- Absence of Terrain Awareness and Warning System (TAWS) on aircraft
- Possible confirmation bias influencing pilot's interpretation of inconsistent instrumentation
- Earlier track deviations not brought to pilot's attention, reducing alertness to GPS problem
Coroner's recommendations
- Air Services Australia should continue enhancements to TAAATS to display aircraft's cleared route on controller screens
- Manual of Air Traffic Services should mandate communication with pilots to resolve Route Adherence Monitoring alerts
- Pilots should be made aware of GPS Dead Reckoning mode operation and associated receiver-generated warning messages through safety advisories
- Consideration of Minimum Safe Altitude Warning (MSAW) systems in TAAATS to activate when aircraft at risk of breaching minimum safe altitude
- Civil Aviation Safety Authority should reconsider introduction of mandatory Terrain Awareness and Warning System (TAWS) requirements for aircraft with passenger capacity similar to PA-31T Cheyenne
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