Finding into death of Daniel Flinn
Deceased
Daniel Flinn
Demographics
55y, male
Date of death
2016-01-29
Finding date
2020-02-11
Cause of death
Multiple injuries sustained in a light plane incident
AI-generated summary
On 29 January 2016, four occupants of a Piper PA-28 aircraft (VH-PXD) departed Moorabbin Airport in Victoria for King Island in poor weather conditions. All three licensed pilots knew conditions were unsuitable for VFR flight but departed collectively. At approximately 12:27 PM, the aircraft entered a rapid descent and impacted water 6.6 km southwest of Point Lonsdale, killing all four occupants. The Australian Transport Safety Bureau investigation determined the pilot likely experienced spatial disorientation after entering low cloud and reduced visibility, with loss of control resulting. The coroner found the three pilots were aware weather breached minimum VFR requirements but continued flying. Key systemic concerns included: pilots holding VFR licenses have insufficient IFR training to manage inadvertent entry into instrument meteorological conditions; the Pilot-in-Command could not be identified; and VFR flight decision-making under pressure to proceed to social events contributed to the accident.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Departure in weather conditions below VFR minimums
- Spatial disorientation after entering low cloud and reduced visibility
- Loss of visual cues during inadvertent entry into instrument meteorological conditions
- Insufficient IFR training and recency for VFR-only licensed pilots
- Group decision-making pressure to proceed to social event despite deteriorating weather
- Pilot decision-making to continue rather than turn back when conditions deteriorated
Coroner's recommendations
- The Civil Aviation Safety Authority mandate the use of a SARTIME (Search and Rescue Time notification) for all Visual Flight Rules flights over water.
- The Civil Aviation Safety Authority increase Instrument Flight Rule training and recency requirements for Private Pilot Licence candidates and holders, for the purpose of, but not necessarily limited to, further education for candidates on the fatal dangers of inadvertent entry into Instrument Meteorological Conditions.
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Source and disclaimer
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