Queensland Coroner Nerida Wilson has recommended Terrain Awareness Warning System (TAWS) be made mandatory in small aircraft after the crash of a Cessna 404 at Lockhart River in 2020.
Five people including the pilot died when VH-OZO struck the ground 3.5 nm short of runway 30 during a second attempt to land in marginal conditions.
The ATSB investigation revealed that the aircraft descended to 1000 feet below the approach path profile for the RNAV, but was unable to provide a reason for this.
Handing down her findings in Cairns yesterday, Wilson concluded the deaths were the result of pilot error, but also recommended CASA mandate TAWS for all passenger-carrying flights in aircraft with more than six seats.
"I note that TAWS was not required to be installed on the Cessna 404 at the time of the incident flight (nor currently)," Wilson said.
"I accept VH-OZO complied with all regulations at the relevant time and did not require fitment of a terrain warning system – however the fact that TAWS was not required in 2020 nor today in 2023 requires serious industry reflection.
"It is the entirely the prerogative of small operators to not fit TAWS. It is also the prerogative of consumers to chose in an open market place, and consumers may now reflect that their employees safety is not negotiable, and reconsider where to take their business."
In her findings, Wilson said she believed that TAWS may have prevented the deaths of the five on board.
"In the circumstances, I am left with little doubt that a functioning terrain avoidance warning system providing visual and aural alerts may have provided the pilot with an opportunity to take the action required to avoid collision.
"In any event, the absence of such a warning system was a missed opportunity to alter the outcome."
Wilson also referred to the crash at Lockhart River in 2005 of Metroliner VH-TFU, which hit a ridge on descent into Lockhart River, killing all 15 on board. A coroner's inquest into that crash also resulted in a recommendation for mandatory TAWS.
"While the circumstances of both are quite different, it is noteworthy, indeed shocking, that 20 people have now died in two plane crashes at Lockhart River within the last 18 years.
"Such significant loss of life has impacted many families and the community of Lockhart River.
"The then State Coroner found that if a properly operating and fully functional [TAWS] had been fitted it is probable the accident would not have occurred ...
"It is now 16 years since the State Coroner’s findings were handed down and the mandatory introduction of the installation of TAWS has not occurred in relation to particular kinds of regular public transport or charter operations, including the Cessna 404 aircraft the subject of these current inquest proceedings."
In a written submission to the inquest, CASA said that it is now "committed to reviewing and reconsidering the position further in the context of commercial operations involving aircraft with a passenger carrying capacity of 6 or more.
"CASA accepts that the occurrence of this accident changes the paradigm upon which it acted in a way which compels the conduct of a fresh analysis of the safety case supporting the TAWS requirements."