Finding into death of Geoffrey Brockie
Deceased
Geoffrey William Brockie; also Belinda Anne Andrews, Kerry David Endicott, Jacqueline Mary Henderson, Robert Harold Henderson, Alan Donald Stark
Demographics
37y, male
Date of death
2004-07-28
Finding date
2011-09-30
Cause of death
injuries sustained as a result of aviation accident
AI-generated summary
A Piper Cheyenne aircraft (VH-TNP) carrying six people crashed near Benalla, Victoria on 28 July 2004. The pilot, Kerry Endicott (aged 69), was highly experienced with over 14,000 flight hours. During instrument meteorological conditions, the aircraft deviated progressively from its cleared GPS approach track. Air traffic controllers failed to alert the pilot to track deviations despite two Route Adherence Monitoring (RAM) alerts. The primary cause was the Trimble GPS operating in dead-reckoning mode, likely due to signal interference at the antenna. Critically, controllers did not communicate track deviations to the pilot as required by procedures. Enhanced radar monitoring, terrain warning systems, and controller adherence to communication protocols regarding navigation alerts could have prevented this accident.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Trimble GPS unit operating in dead-reckoning mode
- Signal interference at GPS antenna
- Air traffic controller failure to communicate track deviations to pilot
- Failure to provide mandatory tracking advice when RAM alerts activated
- Progressive track deviation not brought to pilot attention
- Controlled flight into terrain in instrument meteorological conditions
- Absence of terrain awareness and warning system
- Confirmation bias potentially affecting controller decision-making
Coroner's recommendations
- Air Services Australia to enhance TAAATS with graphic display of aircraft's cleared route on controller's screen (completed)
- Manual of Air Traffic Services to be amended to mandate communication with pilot to resolve RAM alerts (completed)
- Reconsider implementation of Minimum Safe Altitude Warning in TAAATS despite logistical and cost challenges
- Civil Aviation Safety Authority to consider requiring Terrain Awareness and Warning Systems (TAWS) on aircraft with passenger capacity such as TNP
- Pilots to be educated on dead-reckoning GPS operation and associated receiver-generated warning messages
- Review prevention of controlled flight into terrain accidents through improved air safety measures
Full text
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