Finding into death of Ms L
Deceased
Ms L
Demographics
19y, female
Date of death
2015-09-08
Finding date
2019-09-20
Cause of death
Multiple Injuries sustained in an Aviation Incident
AI-generated summary
Ms L, a 19-year-old student pilot, died in an aircraft accident during her first navigational solo flight. The Cessna 172 descended rapidly and impacted rising terrain. Investigation revealed she had engaged the autopilot for approximately one-third of the flight—excessive use beyond her training level and instructions. While manually controlling the aircraft with the autopilot engaged, the autopilot trimmed against her control inputs, creating a mistrim condition that induced rapid nose-down descent. She had limited time to diagnose and recover before ground impact. Critical clinical/safety lessons: inadequate autopilot training at her certification level; absence of manufacturer warnings about autopilot-pilot input conflicts; lack of audible alerts for mistrim conditions. Training organisations should provide comprehensive autopilot system education, and manufacturers should include clear limitations, cautions, and warnings in operating manuals with audible alerts.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Excessive autopilot use beyond training level and instructions
- Inadequate autopilot system training at RPL level
- Manual control inputs applied while autopilot engaged in vertical mode
- Autopilot trim system response to manual control inputs causing mistrim condition
- Lack of manufacturer warnings about autopilot-pilot input conflicts
- Absence of audible alert for mistrim situations
- Low operating height above ground providing limited recovery time
- Rising terrain in flight path
Coroner's recommendations
- Cessna Aircraft Company, in conjunction with Garmin, implement changes to their operations manuals so that all aircraft types fitted with their autopilots have the limitations, cautions and warnings applied consistently
- Garmin, in conjunction with aircraft manufacturers, takes action to ensure that all aircraft types fitted with their autopilots have the limitations, cautions and warnings documented in the aircraft's operating manuals
- Garmin consider the use of audible warnings to enhance pilots' awareness of mistrim situations brought on by the autopilot system
Full text
Related cases
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.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —