ATSB Transport Safety Report - Aviation Occurrence Investigation (Defined) AO-2022-041

About 30 minutes after departing the private property, the pilot had left a verbal flight note3 with a person not associated with the operator to expect their arrival ‘late morning’. This person raised concern for the flight after several attempts to contact the pilot were unsuccessful, and notified the operator at 1309 that the pilot was missing. The operator then attempted to contact the pilot and made several calls to other locations to see whether the aircraft had landed at a different location. At 1331, the operator notified Lowood police and at 1342, arranged for a helicopter from another Archerfield based operator to search for the missing aircraft. At 1344, the operator notified Airservices Australia who coordinated a search and rescue effort with the Joint Rescue Coordination Centre. At about 1427, the helicopter departed Archerfield and located the wreckage shortly after. The helicopter pilot landed near the wreckage and proceeded to the site on foot, and then reported back to the operator that all of the aircraft’s occupants were deceased. Shortly after, a search and rescue helicopter arrived at the site and paramedics confirmed the fatalities. Context Pilot information The pilot held commercial pilot licences (aeroplane and helicopter), with their last aeroplane flight review being conducted in March 2021 and operational proficiency check last completed in March 2022. The pilot also held an aeroplane instrument rating, but this was not current as the last renewal4 was completed in October 2002 (valid until October 2003). 3 Details of the route and timing of a proposed flight provided by the pilot-in-command of an aircraft, other than a notification submitted to Airservices Australia, and which is required to be left with a person who could be expected to notify appropriate authorities if the flight becomes overdue. 4 Before the introduction of the Civil Aviation Safety Authority (CASA) Part 61 licencing regulations in 2014, under Civil Aviation Regulation 5, pilots maintained instrument currency by completing an instrument ‘renewal’. Under Part 61, pilots maintained this currency by completing an ‘instrument proficiency check’. ATSB – AO-2022-041 › 4 ‹ The pilot held a night VFR rating (helicopter), but this was also not current as the last proficiency check was completed in May 2019 (valid until May 2021). The pilot held a Class 1 aviation medical certificate, valid until October 2022. Prior to the accident flight, the pilot had accumulated approximately 13,900 hours of aeronautical experience in helicopters and aeroplanes, of which about 475 hours were in command of the Cessna R182. The pilot also had about 96 hours of instrument flying experience and 22 hours of night VFR experience. Aircraft information The Cessna R182 Skylane RG is a 4-seat, high-wing, single-engine aircraft with retractable landing gear. The accident aircraft was manufactured in the United States in 1978 and first registered in Australia in 1989 as VH-HZU before being purchased by Executive Helicopters in January 2020 and registered as VH-EHM. The aircraft was fitted with a Lycoming O-540 piston engine driving a 3 blade Hartzell constant speed propeller and was equipped for flight under both VFR and instrument flight rules (IFR).5 The last periodic maintenance inspection (100-hourly) was completed on 15 July 2022. Since then, the aircraft had accrued about 30 hours of flight time and had about 5,858 hours total time in service. Terrain The flight’s track towards Archerfield took the aircraft across the Great Dividing Range to the west of Brisbane with terrain elevations generally between 1,500-2,000 ft AMSL. This area also contained numerous peaks between 2,000-2,700 ft (Figure 4). Figure 4: Visual navigation chart extract showing terrain along the flight path Source: Airservices Australia and OzRunways, modified and annotated by ATSB 5 Instrument flight rules (IFR): a set of regulations that permit the pilot to operate an aircraft in instrument meteorological conditions (IMC), which have much lower weather minimums than visual flight rules (VFR). Procedures and training are significantly more complex as a pilot must demonstrate competency in IMC conditions while controlling the aircraft solely by reference to instruments. IFR-capable aircraft have greater equipment and maintenance requirements. Accident site Archerfield Airport Dalby Airport 30 km ATSB – AO-2022-041 › 5 ‹ Meteorological information Forecast The graphical area forecast for the accident region forecast the following cloud conditions at the time of the accident (all heights AMSL): • broken6 stratocumulus between 1,500-2,500 ft • broken cumulus/stratocumulus between 3,000-7,000 ft Isolated smoke was forecast below 6,000 ft where the visibility reduced to 6,000 m. Isolated showers were forecast with 3,000 m visibility and the following cloud conditions: • broken stratocumulus between 1,000-2,500 ft • broken cumulus between 2,500-8,000 ft The grid point wind and temperature chart for the region forecast 1,000 ft easterly winds between 9-13 kt, with temperatures 12-14 °C. Airservices Australia held three National Aeronautical Information Processing System (NAIPS)7 login records for the pilot in the 24-hour period before the accident. These were recorded at 0708, 0709 and 0925 on 29 August 2022. Observations The following METAR8 observations from nearby airports were reported at 1000 (about 7 minutes before the accident): • Royal Australian Air Force Base Amberley (24 km south of accident site) – visibility 8,000 m, cloud scattered at 1,400 ft and broken at 2,800 ft9 • Archerfield Airport (36 km south-east of accident site) – visibility at least 10 km, cloud scattered at 1,900 ft and 2,300 ft, and overcast at 3,300 ft Several witnesses along the aircraft’s route from Dalby to Fernvale recalled seeing the aircraft flying at low altitude below cloud. One witness in Fernvale reported the aircraft flying at low altitude while heading east towards the D’Aguilar Range with the wings level and undercarriage retracted, before banking left (Figure 3) and disappearing from view as it was obscured by cloud. The witness also reported heavy low cloud, very light rain, and fog covering the Fernvale and surrounding area at the time. Airspace The Amberley military control zone extends from ground level up to an altitude of 8,500 ft (Figure 5). The airspace was active from 0800 to 2300 on 29 August and required a clearance to transit. Preliminary information indicated no record of a transit clearance request by the pilot, however, additional information is being collected by the ATSB to verify this. 6 Cloud cover: in aviation, cloud cover is reported using words that denote the extent of the cover – ‘few’ indicates that up to a quarter of the sky is covered, ‘scattered’ indicates that cloud is covering between a quarter and a half of the sky, ‘broken’ indicates that more than half to almost all the sky is covered, and ‘overcast’ indicates that all the sky is covered. 7 The National Aeronautical Information Processing System (NAIPS) is a computerised, aeronautical information system. It processes and stores meteorological and NOTAM information as well as enables the provision of briefing products and services to pilots. 8 METAR: a routine aerodrome weather report issued at routine times, hourly or half-hourly. 9 Cloud heights are reported as above aerodrome elevation. Amberley elevation – 91 ft. Archerfield elevation – 65 ft. ATSB – AO-2022-041 › 6 ‹ Figure 5: Amberley control area Source: Airservices, annotated by ATSB Site and wreckage information The accident site was located within the D’Aguilar Range on a steep section of mountainous terrain covered with trees (Figure 6). Figure 6: Accident site Source: ATSB On-site evidence indicated that the aircraft was in a right turn with an angle of bank of about 47° when it collided with several trees, before impacting terrain about 28 ft vertically below the top of a VH-EHM track Accident site Amberley controlled airspace Archerfield Airport Gatton Airpark 10 km ATSB – AO-2022-041 › 7 ‹ ridge. The wreckage trail extended about 40 m from the initial impact point to the top of a ridge where most of the wreckage was located, including the engine. The propeller was located about 10 m forward of the main impact point. On-site examination indicated that the engine was providing power at impact, with the landing gear and flaps in the retracted position. There was no evidence of an in-flight break-up or a pre-existing defect with the flight controls. Recorded Data The aircraft was not fitted with a flight data recorder or cockpit voice recorder, nor was it required to be. Recorded data was obtained from various sources: • GPS flight track data from OzRunways • ADS-B data10 • CTAF communications • CCTV footage • radar data The flight track data indicated that the aircraft’s ground speed after departing Dalby was generally between 120-140 kt, indicative of normal cruise speeds. Further investigation The ATSB has examined the accident site and wreckage, interviewed witnesses, collected meteorological data, pilot and flight records and obtained aircraft tracking data. The investigation is continuing and will include further review and examination of: • pilot training, qualifications, experience, and medical information • aircraft maintenance and flight records • operator procedures, flight notification practices and management systems • witness accounts • meteorological data • recorded data (CCTV, flight tracking, communications). Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken. A final report will be released at the conclusion of the investigation. Acknowledgements The ATSB would like to acknowledge the significant assistance provided by the Queensland Police Service during the onsite investigation phase and initial evidence collection activities. 10 Automatic Dependent Surveillance – Broadcast - A means by which aircraft, aerodrome vehicles and other objects can automatically transmit and/or receive data such as identification, position and additional data, as appropriate, in a broadcast mode via a data link. ATSB – AO-2022-041 › 8 ‹ General details Occurrence details Aircraft details Date and time: 29 August 2022 – 1007 Eastern Standard Time Occurrence class: Accident Occurrence categories: Collision with terrain Location: 24 km north of Amberley, Queensland Latitude: 27º 25.548' S Longitude: 152º 40.731' E Manufacturer and model: Cessna Aircraft Company R182 Registration: VH-EHM Operator: Executive Helicopters Serial number: R18200431 Type of operation: Part 135 Australian air transport operations - Smaller aeroplanes Departure: Dalby Aerodrome Destination: Archerfield Aerodrome Persons on board: Crew – 1 Passengers – 2 Injuries: Crew – 1 (fatal) Passengers – 2 (fatal) Aircraft damage: Destroyed