Finding into death of Mangalore Aircraft Accident
Deceased
Christiaan Gobel, Pasinee Meeseang, Ido Segev, Peter Phillips
Demographics
unknown
Date of death
2020-02-19
Finding date
2024-07-31
Cause of death
Multiple injuries sustained in an aviation incident
AI-generated summary
Mid-air collision between two IFR-certified aircraft near Mangalore, Victoria on 19 February 2020, killing four experienced pilots/instructors. Both aircraft were operating in Class G uncontrolled airspace under instrument flight rules with limited visual conditions. Air traffic controller provided traffic information to both aircraft but no safety alert was issued after Short-Term Conflict Alerts activated. Critical factor was absence of effective communication between the two aircraft crews on the common traffic advisory frequency to arrange self-separation, despite receiving traffic information. While visual acquisition was highly unlikely given meteorological conditions and closing speed, the lack of crew coordination via radio communication after ATC traffic calls was identified as material contributing factor. Coroner found no criticism of ATC's decision-making in real-time but identified absence of inter-aircraft communication as the key failure leading to collision.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Absence of or lack of effective communication between the pilots of the two aircraft on the common traffic advisory frequency after traffic information was provided
- Instrument meteorological conditions that severely limited visual acquisition capability
- Incorrect departure call by JQF pilot that did not specify whether aircraft was 'tracking to' or 'tracking to intercept' the departure track, creating potential ambiguity about flight path
- See-and-avoid principle being unreliable in the instrument flight conditions and at the closing speed of the aircraft
- Neither aircraft equipped with ADS-B receiving capability to provide electronic traffic awareness
Coroner's recommendations
- CASA develop and disseminate educational material for the aviation industry reinforcing the importance of accurate departure calls being made by pilots in command of aircraft
- Airservices provide additional training to Air Traffic Controllers on managing and responding to Short-Term Conflict Alerts within 5 nautical miles of aerodromes with similar aircraft movements to Mangalore in anticipation of harmonisation of Brisbane and Melbourne operating requirements
- Airservices consider providing additional training to current and prospective Air Traffic Controllers on the use of velocity vectors in Class G airspace
- ATSB, AMSA and CASA continue to work together to promote the voluntary uptake of ADS-B technology in Australian-registered aircraft
- CASA conduct a cost-benefit study into the feasibility and potential benefits of requiring the installation of ADS-B IN devices in IFR-certified aircraft
- Minister for the Commonwealth Department of Infrastructure give consideration to expanding the ADS-B rebate program to extend to Australian registered IFR aircraft
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