Finding into death of Mount Disappointment Helicopter Accident
Deceased
Ian Perry, Dean Neal, Shashi Vasudeva, Paul Troja, Linda Woodford
Date of death
2022-03-31
Finding date
2024-08-28
Cause of death
Multiple injuries sustained in a helicopter incident
AI-generated summary
Five people died in a helicopter crash at Mount Disappointment on 31 March 2022. The pilot, Dean Neal, had no instrument flying training and was only authorised for visual flight rules (VFR). Despite weather forecasts indicating cloud development unsuitable for VFR operations, the flight proceeded. When cloud layers converged, the pilot attempted a sharp U-turn without visual references, lost control during the manoeuvre, descended rapidly, and struck terrain. The coroner found that instrument flying training would have equipped the pilot with skills to recover from inadvertent instrument meteorological conditions (IIMC). Regulatory gaps were identified: CASR Part 133 does not mandate basic instrument flying training for commercial helicopter pilots or recovery procedures for inadvertent IMC encounters. The coroner recommended mandatory instrument flying training be included in commercial helicopter pilot requirements and operator proficiency checks.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Pilot had no instrument flying training or experience
- Pilot was not authorised to fly in instrument meteorological conditions
- Flight planned for visual meteorological conditions despite weather forecast indicating broken cloud at 2,000-8,000 feet
- Pilots continued flight towards deteriorating cloud and reduced visual cues below required VMC
- Pilot lost control during attempted U-turn to exit from IMC
- High rate of descent (5,700 feet per minute) developed during the turn
- Helicopter not equipped with autopilot or stability augmentation system
- No inadvertent IMC recovery procedure published by operator
- No mandatory inadvertent IMC recovery training by operator
- No pre-flight risk assessment process at operator
- Operator risk assessment did not consider IIMC risk controls
- CASR Part 133 does not require basic instrument flying training for commercial helicopter pilots
- CASR Part 133 does not require IIMC recovery training or procedures
- Incorrect assessment of weather by pilots before and during flight
Coroner's recommendations
- CASA amend CASR (Part 133) to introduce a mandatory instrument flying component (including recovery from IIMC events) to the requirements for a commercial pilot licence for helicopters carrying passengers, together with a requirement for such training to be included in proficiency checks conducted by operators
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