Finding into death of Robert Harold Henderson
Deceased
Robert Harold Henderson
Demographics
62y, male
Date of death
2004-07-28
Finding date
2011-09-30
Cause of death
Injuries sustained as a result of an aviation accident
AI-generated summary
Six people, including pilot Kerry Endicott and passenger Robert Harold Henderson, died in an aviation accident on 28 July 2004 when a Piper Cheyenne aircraft collided with terrain near Myrrhee, Victoria. The pilot was highly experienced with more than 14,000 hours of flying experience and had been medically cleared for aviation duties despite having chronic atrial fibrillation and coronary atherosclerosis. Medical investigation confirmed the pilot was not incapacitated at the time of the accident. The coroner's inquiry focused on three key issues: whether pilot medical incapacity occurred, whether air traffic controllers acted appropriately, and whether GPS failure contributed. Investigators identified significant failures by air traffic controllers who did not communicate critical track deviation alerts to the pilot, creating lost opportunities to prevent the accident. The coroner concluded the probable cause was navigation in GPS dead reckoning mode, possibly triggered by loss of signal to the cockpit receiver unit.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Navigation error with Trimble GPS operating in dead reckoning mode
- Failure of air traffic controllers to communicate track deviations to the pilot
- Air traffic control system limitations and procedure ambiguities regarding route adherence monitoring alerts
- Pilot's reliance on GPS display without detecting warning signs of malfunction
- Absence of terrain awareness and warning systems
- Instrument meteorological conditions reducing visual cues
Coroner's recommendations
- Enhancement of TAAATS with display of aircraft's cleared route on controller screens (commended as implemented)
- Amendment of MATS to mandate communication with pilots regarding route adherence monitoring alerts (commended as implemented)
- Implementation of training and awareness programs for pilots regarding dead reckoning mode GPS operation and associated warning messages
- Implementation of Terrain Awareness and Warning Systems (TAWS) on aircraft with passenger capacity similar to TNP
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