The Australian Transport Safety Bureau yesterday released the investigation report into the crash of a Grumman Mallard into the Swan River at Perth in 2017.
VH-CQA was taking part in an Australia Day display over Perth Water on 26 January 2017 when it crashed into the river during the display. The pilot and passenger were killed and the aircraft destroyed.
The pilot of the aircraft had already completed two passes across Perth Water in front of Langley Park behind Caravan floatplane VH-MOX, when the pilot requested a third, unplanned pass.
"The aircraft then returned to the display area without the Caravan and in a manner contrary to the standard inbound procedure, requiring turns at higher bank angles and lower altitudes within a confined area to become established on the display path," the ATSB states.
"The ATSB investigation found that the aircraft stalled at an unrecoverable height. Had the Mallard re-entered the display area using the standard procedure for the air display, the manoeuvres required to position for the third pass would have been relatively benign with a significantly reduced risk of mishandling the aircraft."
Much of the ATSB report focuses on the CASA approval process put in place at the time, and the pilot's decision to carry a passenger during the display.
"CASA did not have an effective frame work to approve and oversight air displays," the report states, "predominantly due to the following factors:
- while the Air Display Manual provided guidance to organisers conducting an air display, it did not inherently provide the processes and tools needed for CASA to approve and oversee one and no other documented guidance existed
- unlike the accreditation models adopted by some other countries, CASA did not have a systemic approach for assessing the suitability of those responsible for organising, co-ordinating and participating in air displays
- CASA did not have a structured process to ensure that risks were both identified and adequately treated."
The ATSB noted that the pilot had also flown CQA at Evans Head with a passenger and was told by CASA that the person did not form "essential crew" and therefore should not have been on the aeroplane during the display. That information had not been conveyed to the CASA staff who approved the Swan River display. The pilot said the passenger was essential to help extend the landing gear in the event of a system failure. However, the ATSB was unable to find support for that from other Mallard pilots.
Since the accident, CASA has released a new Air Display Manual that addressed some of the issues raised by the ATSB including the requirement for detailed risk assessments.
The full investigation report is available on the ATSB website.