What happened
On 31 March 2022, two Airbus Helicopters EC130 aircraft, operated by Microflite, departed Melbourne's Batman Park for a passenger transport flight to Ulupna. The lead aircraft, VH-WVV, and the trailing aircraft, VH-XWD, flew toward the Mount Disappointment area.
As the flight progressed, the pilots chose a route over the ranges rather than a safer alternative via Kilmore Gap, based on an assessment of weather forecasts. While the lead aircraft, VH-WVV, performed a U-turn to avoid entering cloud, the second aircraft, VH-X/XWD, entered a high rate of descent while attempting to follow the same maneuver. This resulted in a collision with terrain. The accident resulted in 5 fatalities and the destruction of the aircraft.
The investigation
The investigation examined the route planning, the pilots' weather assessments, and the aircraft's equipment. It was found that the pilots relied heavily on a Melbourne Airport forecast that did not accurately reflect the cloud heights over the ranges. While the pilots were aware of the weather, they failed to associate the risks of their chosen route with the forecast conditions.
Additionally, the investigation looked into the pilot's ability to fly in instrument meteorological conditions (IMC). The pilot of VH-XWD lacked instrument flying experience and was not trained to fly solely by reference to instruments. The aircraft was also not equipped with an autopilot or stability augmentation system, which could have assisted in maintaining control. Furthermore, the standby artificial horizon was not activated and provided conflicting data, contributing to pilot distraction.
Findings
- The pilots selected a route that was unsuitable for visual flight based on an incorrect weather assessment.
- The aircraft entered deteriorating cloud, leading to a loss of visual cues.
- The pilot was unable to maintain pitch attitude during a 180-degree turn in the cloud, leading to the high rate of descent.
- The operator, Microflite, lacked mandatory IIMC recovery training and published procedures for its VFR pilots.
- There was no requirement for pilots to perform pre-flight risk assessments for these tasks.
- The operator's risk management for poor weather did not specifically address the risks of inadvertent IMC encounters.