Two helicopter pilots flying in company with each other chose an inappropriate path for weather conditions that led to the fatal crash of one of the helicopters, according to an ATSB investigation report released today.
The two EC130s were carrying charter customers from the Batman Park helipad to Ulupna on the Murray River on 31 March 2022, when they encountered marginal weather conditions over Mount Disappointment.
The lead helicopter, VH-WVV, conducted a 180-degree turn to escape from IMC, but the pilot of the following aircraft, VH-XWD, lost control attempting to turn around, resulting in a collision with terrain that killed all five people on board.
“During the attempted U-turn without visual cues the second helicopter developed a high rate of descent, resulting in the collision with terrain,” said ATSB Chief Commissioner Angus Mitchell.
“Unfortunately, the pilot had no instrument flying experience, and the helicopter was not equipped with any form of artificial stabilisation, albeit neither of which are required for VFR flying.”
The ATSB investigation discovered the pilots put more importance on the Melbourne Airport forecast rather than the Graphical Area Forecast (GAF). The Melbourne forecast suggested the Kilmore Gap was subject to TEMPOs, which would have cloud sitting on the ground. Visual checks of cloud after leaving Batman Park led the pilots to believe the Mount Disappointment route would be the best way through.
Mitchell noted that helicopter operator had not incorporated several available risk controls for their day VFR pilots to mitigate against inadvertent entry into IMC, nor were they required to by regulations.
“These risk controls may have included inadvertent IMC recovery training and basic instrument flying competency checks during operator proficiency checks,” Mitchell said.
The operator had also not introduced an IMC recovery procedure for their air transport operations, or a pre-flight risk assessment for marginal weather conditions identified during pre-flight planning.
ATSB investigators also noted that CASR Part 133 Air Transport Operations–Rotorcraft did not stipulate any recovery procedures for inadvertent VFR into IMC other than a warning to avoid the situation.
CASA CEO and Director of Aviation Safety Pip Spence said that it was important to look at what went wrong, and what could be learnt to prevent similar accidents occurring in the future.
"All pilots will encounter bad weather at some stage in their flying careers," Spence said in a statement responding to the ATSB report.
"Thorough pre-flight planning and understanding of weather forecasts and meteorological conditions help pilots determine if the weather is acceptable for a visual flight rules flight.
"However, it is also important that pilots are able to recognise deterioration in the weather to make an early and safe decision to turn back while in clear conditions – this action will avoid flying into conditions for which they are not trained and equipped.
"We encourage pilots to refresh their skills using the tools and resources available on CASA’s pilot safety hub."
The full investigation report is on the ATSB website.