Finding into death of Mathew Martin Farrell

Contributing factors

• Loss of control in flight due to VFR into IMC (visual flight rules into instrument meteorological conditions)
• Spatial disorientation in cloud after loss of external visual reference
• Icing of aircraft airframe and propeller at altitude above 4,500 feet
• Poor weather conditions unsuitable for VFR flight
• Inadequate flight training - only 14.7 hours total, compressed into single intensive day
• Improperly issued pilot certificate via converting pilot pathway
• Improperly issued cross-country endorsement
• Lack of human factors training and understanding of decision-making biases
• Over-confidence of novice pilot
• Flight instructor's failure to instil caution and humility
• Mountainous terrain with rapid weather deterioration
• No formal flight plan filed
• Aircraft limited to VMC only (no instruments or de-icing capability)

Coroner's recommendations

1. CASA to review the conduct of RAAus during this investigation and inquest, including the conduct of its officers and key personnel
2. CASA to facilitate amendments to Section 2.13 of the RAAus Flight Operations Manual to clarify aeronautical experience constituting recognised flight time by aircraft type/group, clarify experience required for endorsements, and clarify whether flight testing for endorsements may be conducted concurrently
3. CASA to facilitate amendments to RAAus Flight Operations Manual to include definitions of 'aeroplane' and 'aircraft' consistent with Civil Aviation Safety Regulations 1998 and Civil Aviation Act 1988
4. RAAus to develop standardised training records for flight instructors that permit detailed auditing of training delivered, are in form approved by CASA, and must be used by all RAAus flight instructors in all instances
5. ATSB should investigate all fatal accidents involving RAAus registered aircraft, given RAAus declaration that it will no longer investigate fatal accidents