Background
The Australian Transport Safety Bureau (ATSB) investigated an accident involving a visual flight rules (VFR) pilot operating a community service flight. The investigation identified no mechanical defects, and the aircraft was serviceable at the time of the accident. A review of the pilot’s medical records and postmortem examination results did not identify any acute or pre-existing medical conditions that may have contributed to the accident.
Flight Details
The pilot departed from Murray Bridge at about 0800, with weather forecasts indicating marginal visual meteorological conditions (VMC) at the destination, Mount Gambier, but with expected improvement from 0930. The pilot’s planned arrival was between 0930 and 1000. The Mount Gambier aerodrome forecast (TAF) released at 0942 also indicated marginal but improving conditions. However, the SPECI and live weather observations available to the pilot en route indicated that observed conditions, while improving, were not suitable for VFR.
It could not be determined if the pilot accessed this information en route, but weather-related diversions were noted in the recorded flight path, and radio calls requesting the cloud base at Mount Gambier were made. The pilot conducted a non-standard, high-risk approach and landed at Mount Gambier in conditions not suitable for VFR flight. Shortly after, the pilot departed again, and the short duration between landing and take-off, considering passenger loading, indicated a limited opportunity to check weather conditions.
Decision-Making Factors
The investigation considered possible reasons for the pilot’s decision to continue to land rather than divert or hold, and subsequently depart. The factors were based on an empirical study of pilot decision-making relating to VFR flight into adverse weather: situation assessment, risk perception, and other motivational factors.
Situation Assessment
The pilot did not hold an instrument rating, had limited exposure to instrument flight conditions in training, and had held his licence for about four years at the time of the accident. The pilot may have interpreted information from other pilots on the Mount Gambier common traffic advisory frequency to indicate that a landing was plausible, when conditions were marginal even for instrument flight rules (IFR). However, insufficient evidence exists to establish whether the pilot accurately assessed the conditions.
Risk Perception
The pilot’s perception of the risk associated with departure from Mount Gambier is not known. En route, the pilot conducted weather-related track diversions, indicating awareness of adverse weather. He then conducted a non-standard approach and landed in low visibility, encountering difficulty in sighting and landing. There is insufficient evidence to determine if the pilot accurately assessed the risk of departing in similar conditions.
Conclusion
The ATSB did not state a probable cause for this accident. The investigation highlighted risks related to community service flights, including regulatory aspects and the importance of pilot decision-making in adverse weather.