Coronial
WAother

Inquest into the Death of Roulston, Bradleigh Michael and Kean, Daniel Joseph

Deceased

Roulston, Bradleigh Michael and Kean, Daniel Joseph

Demographics

23y, male

Date of death

2008-02-13

Finding date

2013

Cause of death

Multiple injuries sustained in mid-air collision between aircraft

AI-generated summary

Two aircraft collided mid-air during goat culling operations in February 2008: a Piper Super Cub (pilot Bradleigh Roulston, age 23; spotter Daniel Kean, age 39) and a Robinson R44 helicopter. Both occupants of the Super Cub died from multiple injuries. The collision was avoidable and resulted from multiple factors: absence of formalised aircraft separation protocols, both aircraft flying at similar altitude when the helicopter should have been significantly lower, both pilots' failure to take evasive action or communicate warnings despite observing convergence, and pilot fatigue following extended flying hours in extreme heat. The coroner found fatigue played a significant role in poor decision-making. The helicopter pilot turned left rather than the standard right turn for converging aircraft and climbed rather than descending. Critical clinical lesson: human factors including fatigue severely impair judgment in safety-critical roles; fatigue management protocols and technological safeguards are essential.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • Pilot fatigue from prolonged flying hours over multiple days in extreme heat (39-42°C)
  • Absence of formalised aircraft separation protocols and guidelines
  • Both aircraft flying at similar altitude when separation should have been maintained
  • Failure of pilots to communicate warnings despite observing convergence
  • Lack of evasive action by pilots immediately before collision
  • No relief pilots despite arduous working conditions
  • Inadequate visual separation awareness in small aircraft operations
  • Helicopter pilot making left turn instead of standard right turn for converging aircraft

Coroner's recommendations

  1. DEC and DAF should put in place guidelines for aerial work covering feral animal culling with at least a 500 foot vertical buffer between spotter and shooter aircraft in addition to any horizontal buffer
  2. DEC and DAF should take action to ensure ongoing consideration is given to possible use of available anti-collision systems, particularly the FLARM system
Full text

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