Coronial
VICother

Finding into death of John Christopher Hender

Deceased

John Christopher Hender

Demographics

49y, male

Date of death

2006-03-12

Finding date

2013-06-05

Cause of death

Injuries received in aviation accident

AI-generated summary

A 49-year-old amateur pilot died when his experimental aircraft stalled and crashed near Mildura Aerodrome during a night landing attempt in adverse weather. Multiple contributing factors aligned: the aircraft had a Cessna 310 carburettor known to cause stalling in steep climbs; the pilot's airworthiness certificate had expired in 2003 but he flew anyway; he failed to monitor mandatory radio frequencies and missed critical weather updates; he approached at night despite Visual Flight Rules restrictions; and fuel levels may have been marginal. The coroner identified regulatory failures by CASA in certifying modified experimental aircraft and ATSB in not investigating despite risks to commercial aircraft. Key lessons: regulatory oversight of amateur-built aircraft modifications needs strengthening, pilots must maintain radio competency and continuous monitoring, and expired certificates require better enforcement.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

aviation medicine

Error types

communicationsystemdiagnostic

Contributing factors

  • Aircraft equipped with Cessna 310 twin-engine carburettor known to cause stalling in steep climbs and banks
  • Pilot unaware certificate of airworthiness had expired in 2003
  • Failure to monitor mandatory CTAF radio frequency during approach
  • Pilot did not receive updated weather information issued at 7:54 pm
  • Unexpected early arrival of cold front with dust storm and gusty southwesterly winds
  • Pilot approached during night conditions despite Visual Flight Rules restriction
  • Possible low fuel levels (estimated 5-6 gallons per tank)
  • Attempted steep climb and right-hand bank at low altitude with aircraft operating at maximum power
  • Pilot misled family about certificate expiry and licence conditions

Coroner's recommendations

  1. ATSB reconsider resource allocation to investigate incidents involving amateur-built experimental aircraft at or near non-towered regional aerodromes used by commercial aircraft
  2. CASA require applicants for Australian Flight Radiotelephone Operator Licence to demonstrate radio competency across spectrum of frequencies used to communicate weather and other information at non-towered regional aerodromes
  3. CASA require bi-annual review of radio competency for Flight Radiotelephone Operator Licence holders to access weather and other information on all radio frequencies in their local area
  4. CASA require applicants for Special Airworthiness Certificate (Experimental) for modified kit-built experimental aircraft to provide comprehensive risk identification and mitigation analysis demonstrating consideration of modification effects on flight behaviour
  5. CASA ensure Annexures to Special Certificates of Airworthiness (Experimental) prohibit landing and takeoff from public non-towered regional aerodromes during times commercial passenger aircraft operate
  6. CASA notify owners when time-limited Special Certificates of Airworthiness (Experimental) are due to expire and remind them aircraft cannot be flown without current certificate
  7. CASA ensure time-limited Certificates of Airworthiness (Experimental) do not display 'Unlimited' on front page
  8. CASA actively target pilots of amateur-built experimental aircraft accessing public non-towered regional aerodromes for enforcement and deterrence
  9. Government amend Civil Aviation Rule 166 to require amateur-built experimental aircraft to carry radio equipment capable of receiving weather and other information on all radio frequencies used in their local area
Full text
Official source Archived copy

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

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