iscover
The ATSB suspects a reluctance to change plans was behind a pilot’s fatal decision to fly visually into poor weather west of Brisbane just under a year and a half ago.
The Cessna R182 Skylane RG VH-EHM, operated by Executive Helicopters, was carrying two passengers and a pet dog from a property near Roma to Brisbane’s Archerfield Airport when it crashed in the D’Aguilar Range in August 2022, killing all on board.
According to the ATSB’s report, the pilot – despite only being qualified for flight in visual conditions – chose to continue towards forecast poor weather around the Lake Manchester VFR route after a refuelling stop in Dalby. The plane crashed during a turn around 36km from Archerfield.
“The aircraft very likely entered cloud while manoeuvring in this area, resulting in the pilot losing visual reference with the ground, eventually leading to controlled flight into terrain,” said ATSB chief commissioner Angus Mitchell.
“The pilot was probably influenced by plan continuation bias – an internal pressure or desire to get to the destination – to continue the flight, which probably became stronger as they got closer to Archerfield.”
The transport safety watchdog was unable to determine why the pilot chose to continue despite the risks of unsuitable weather and high terrain, considering it unlikely that there was “any direct or perceived organisational pressure” to do so.
Mitchell has warned VFR pilots to be aware of the “subtle pressures” to carry on with previous plans despite the dangers.
“Be prepared to amend and delay plans to fly due to poor or deteriorating weather and environmental conditions, and not to push on,” Mitchell said.
“Have alternate plans in case of unexpected changes in weather, and make timely decisions to turn back, divert or hold in an area of good weather.”
He also noted that Executive Helicopters did not, at the time, identify inadvertent entry into non-visual conditions in its hazard and risk register, though the ATSB does not believe this was a contributing factor to the crash.
“Not including inadvertent entry into non-visual conditions in its hazard and risk register – which formed part of the operator’s safety management system – reduced the operator’s ability to effectively manage that risk,” Mitchell said.
Executive Helicopters has since taken aeroplanes off its AOC and is implementing additional risk controls for helicopter pilots, including formal policies for landing or returning to a safe site if unable to maintain visual weather conditions, and adding techniques for avoiding and recovering from inadvertent entry into non-visual conditions to its annual operator proficiency checks.
