Ganter, Wayne Joseph; Rawlings, Mark Robert; Roebig, Henry Phillip; Brischke, Wayne Anthony; and Weavell, Stuart Henry Russell…

Male·Multiple injuries due to or as a consequence of an aircraft accident (controlled flight into terrain)

On 11 March 2020, a Cessna 404 aircraft carrying five people crashed near Lockhart River, Queensland, killing all occupants. The pilot attempted two RNAV GNSS instrument approaches in poor weather with heavy rain and low visibility. During the second approach, the pilot was flying approximately 1,000 feet below the recommended descent profile. Analysis indicates the pilot likely misread his analogue altimeter due to very high workload from single-pilot operations in instrument meteorological conditions, lateral navigation corrections, excessive airspeed, and rain. The pilot descended below minimum descent altitude and impacted sand dunes 6.4 km short of the runway. A terrain avoidance warning system (TAWS) was not installed, though fitting one would likely have prevented the accident. Key lessons include the critical importance of mandating TAWS installation for commercial charter operations, upgrading to modern avionics providing vertical guidance, improving stabilised approach criteria aligned with international best practice (1000 ft applicable height in IMC), and enhancing pilot proficiency monitoring in instrument approaches.